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£»■ 


LECTURES  ON 


ANGINA  PECTORIS 

AND   ALLIED   STATES 


BY 

WILLIAM  OSLER,   M.  D. 

FELLOW   OF   THE    ROYAL   COLLEGE   OF    PHYSICIANS,    LONDON 

PROFESSOR   OF    MEDICINE,    JOHNS   HOPKINS    UNIVERSITY,    BALTIMORE 

AUTHOR   OF    A    PRACTICE    OF   MEDICINE 

LECTURES   ON   THE   DIAGNOSIS   OF   ABDOMINAL   TUMORS,    ETC. 


NEW    YORK 

D.    APPLETON    AND    COMPANY 

1897 


i 


Y^ 


rC 

07 


X 

X 

■A 


Copyright,  1896,  1897, 
Br  D.  APPLETON  AND  COMPANY. 


I 


i 


•  t  ^ 


•if  ^      ^ 


TO 

W.  T.  GAIPDNER,  M.D.,  F.R.S., 

REGIUS  PROFESSOR  OF  MEDICINE  IN  THE  UNIVERSITY  OF  GLASGOW. 


Dear  Dr.  Oairdner : 

Please  accept  the  dedication  of  this  little  volume 

in  token  of  the  appreciation  which  your  cis-atlantic 

brethren  feel  of  the  value  of  yout   life  and  work  in 

our  profession. 

Sincerely  yours, 

William  Osler, 


NOTE. 

These  lectures  were  delivered  to  the  graduate  class  in 
medicine  at  the  Johns  Hopkins  Hospital,  and  appeared  in 
The  Neil)  York  Medical  Journal,  1896,  vol.  Ixiv.  They  are 
here  republished  with  slight  additions  and  corrections. 


* 

I 
■It 


CONTENTS. 


LECTURE  I. 

History  of  the  recognition  of  angina.-Heberden.  Rougnon.  Morgagni. 
-Literature.-Deflnition.-Form3  of  heart  pain.-Classification 
of  the  forms  of  angina.-Physiology  and  pathology  of  the  coro- 
nary  arteries 

LECTURE  n. 

•       ANGWA  PECTOftIS  VERA.     AETIOLOGY.     GENEBAL  DESCRIPTION  OF 

THE  DISEASE. 

Incidence  of  the  disease.-Station  in  life.-Ses.-Age.-Epidemic  in- 
fluences.- Heredity.  -  Gout.  -  Diabetes.  -  Syphihs.  -  Specific  fe- 
vers.— Heart  disease.— Locomotor  ataxia.— General  picture  of  the 
disease 

LECTURE  in. 

ANGINA  PECTORIS  VERA.      PHENOMENA  OF  THE  ATTACK. 

Exciting  causes.— Symptoms.— State  of  heart  and  pulse.— Pericarditis. 
—Respiratory  features.— Gastro  -  intestinal  symptoms.— Nervous 
and  psychical  symptoma 

LECTURE  IV. 

ALLIED  AND  ASSOCIATED  CONDITIONS. 

I.  Syncope  anginosa.— II.  The  Adams-Stokes  syndrome.— HI.  Angina 
sine  dolore.— IV.  Cardiac  asthma 

LECTURE  V. 

PSEUDO-ANGINA  PECTORIS. 

I.  Neurotic  group :  (a)  Hysterical  and  neurasthenic  cases ;  (b)  Angina 
pectoria  vaso-motoria;  (c)  Reflex  angina.— 11.  Toxic  angina:  forms 
of  heart  pain  from  tobacco 


PAQB 


20 


45 


67 


86 


^  CONTENTS. 

LECTURE  VI. 

THEORIES  OF  ANGINA.  p^^g 

The  importance  of  coronary  artery  disease.— Intermittent  claudication. 
—State  of  the  heart  muscle  in  an  attack.— Seat  and  cause  of  the 
pain.— Vaso-motor  changes  in  angina.— Relations  of  spurious  and 
true  angina HI 

LECTURE  VII. 

DIAGNOSIS,  PROGNOSIS,  AND  TREATMENT  OF  ANGINA. 

Anomalous  cases  of  heart  pain.— Elements  in  the  diagnosis  of  true 
angina.— Differentiation  of  true  and  pseudo  angina. — Prognosis. 
—Treatment  of  angina  pectoris  vera.— Treatment  of  false  angina. 
— Conclusion 131 

APPENDIX. 

Note  A. — Rougnon's      " 157 

"     B.— The  case  0*  'atthew  Arnold 158 

"     C— Retention  <  J  consciousness  after  apparent  cessation  of 

heart's  action 160 


f 


OK 


,11 


31 


[57 
[58 

L60 


But  wel  I  woot  thou  doost  my  herfe  to  erme 

That  I  almost  have  ^xnght  a  cardiacle. 

The  wordes  of  the  Host  to  the  Phisicien 
and  the  Pardoner.— Chaucer. 


^ 


LECTURES  ON  ANGINA  PECTORIS 
AND  ALLIED  STATES. 


LECTURE  I. 

History  of  the  recognition  of  angina.— Eeberden,  Rougnon,  Morgagni.—Lit- 
eraturo.  —Definition.— Forms  of  iieart  pain.— Classification  of  the  forma 
of  angina. — Pliysiology  and  pathology  of  the  coronary  arteries. 

The  history  of  the  recognition  of  the  disorder  known  as  an- 
gina pectoris  is  connected  with  the  names  of  three  celebrated 
men — Ileberden,  Jenner,  and  John  Hunter. 

On  July  21, 17G8,  Ileberden  read,  at  the  Royal  College  of 
Physicians,  a  paper  entitled  Some  Account  of  a  Disorder  of  the 
Breast,  which  was  published  in  vol.  ii  of  the  Medical  TranS' 
actions  of  the  College  of  Physicians,  1772.  An  extract  from 
the  original  description  must  be  quoted:  "  There  is  a  dis- 
order of  the  breast,  marked  with  strong  and  peculiar  symp- 
toms, considerable  for  the  kind  of  danger  belonging  to 
it.  .  .  .  The  seat  of  it  and  sense  of  strangling  and  anxiety 
with  which  it  is  attended  may  make  it  not  improperly  be 
called  angina  pectoris. 

"  Those  who  are  afflicted  with  it  are  seized  while  they  are 
walking,  and  more  particularly  when  they  walk  soon  after  eat- 
ing, with  a  painful  and  most  disagreeable  sensation  in  the 
breast,  which  seems  as  if  it  would  take  their  life  away  if  it  were 
to  increase  or  to  continue;  the  moment  they  stand  still  all  this 
uneasiness  vanishes.  In  all  other  respects  the  patiei/s  are  at 
the  beginning  of  this  disorder  perfectly  well^  and,  in  particu- 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


'  II 


lar,  have  no  shortness  of  breath,  from  which  it  is  totally  dif- 
ferent." 

Subsequently,  in  the  celebrated  Commentaries  upon  which 
our  grandfathers  in  the  profession  were  educated,  lleberden 
gave  a  fuller  account  of  his  experience  with  the  disease.  The 
name  which  he  adopted  can  not  be  regarded  as  altogether  sat- 
isfactory, since  it  was  already  in  use  in  designating  aifectiong 
of  the  threat,  with  which  its  literal  meaning — a  strangling — 
is  much  more  in  harmony.  In  one  sense,  however,  the  term  is 
fairly  appropriate,  since,  as  noted  by  Gairdner,  the  words  anx- 
iety and  anguish,  expressive  of  two  of  the  most  prominent  fea- 
tures of  the  disease,  have  a  derivation  from  the  same  Greek 
word  as  angina. 

In  1773,  John  Hunter  had  his  first  attack,  wliich  was 
graphically  described  by  his  nephew,  Everard  Home:  "  While 
he  was  walking  about  the  room  he  cast  his  eyes  on  the  looking- 
glass,  and  observed  his  countenance  to  be  pale,  his  lips  white, 
giving  the  appearance  of  a  dead  man.  This  alarmed  him  and 
led  him  to  feel  for  his  pulse,  but  he  found  none  in  either  arm; 
the  pain  continued,  and  he  found  himself  at  times  not  breath- 
ing. Being  afraid  of  death  soon  taking  place  if  he  did  not 
breathe,  he  produced  the  voluntary  act  of  breathing  by  work- 
ing his  lungs  by  the  power  of  the  will."  In  1776  he  had  a 
second  attack,  and  when  convalescent  he  visited  Bath.  Here 
he  was  seen  by  his  friend  and  pupil,  Edward  Jenner,  of  Berke- 
ley; and  one  of  the  most  interesting  and  sagacious  letters 
of  that  distinguished  man  was  written  to  Heberden,  giving 
his  diagnosis  of  John  Hunter's  case,  and  suggesting,  for  the 
first  time,  the  probable  association  of  disease  of  the  coronary 
arteries  with  angina  pectoris.  The  letter  is  worth  quoting 
in  full:  *  "  When  you  are  acquainted  with  my  motives,  I 


•  Baron's  Life  of  Jenner,  London,  1827. 


•■1 


HISTORY  OF  THE  RECOGNITION  OP  ANGINA.  3 

presume  you  will  pardon  the  liberty  I  take  in  addressing  you. 
I  am  prompted  to  it  from  a  knowledge  of  the  mutual  regard 
that  subsists  between  you  and  my  worthy  friend  Mr.  Hunter. 
"When  I  had  the  pleasure  of  seeing  him  at  Bath  last  autumn 
I  thought  he  was  affected  with  many  symptoms  of  the  angina 
pectoris.  The  dissections  (as  far  as  I  have  seen)  of  those 
who  have  died  of  it  throw  but  little  light  upon  the  subject. 
Though,  in  the  course  of  my  practice,  I  have  seen  many  fall 
victims  to  this  dreadful  disease,  yet  I  have  only  had  two  op- 
portunities of  an  examination  after  death.  In  the  first  of 
these  I  found  no  material  disease  of  the  heart,  except  that  the 
coronary  artery  appe.  red  thickened. 

"  As  no  notice  had  been  taken  of  such  a  circumstance  by 
anybody  who  had  written  on  the  subject,  I  concluded  that  we 
must  still  seek  for  other  causes  as  productive  of  the  disease; 
but,  about  three  weeks  ago,  Mr.  Paytherus,  a  surgeon  at  Ross, 
in  Herefordshire,  desired  me  to  examine  with  him.  the  heart 
of  a  person  who  had  died  of  the  angina  pectoris  a  few  days 
before.  Here  we  found  the  same  appearance  of  the  coronary 
arteries  as  in  the  former  case.  But  what  I  had  taken  to  be 
an  ossification  of  the  vessel  itself,  Mr.  P.  discovered  to  be  a 
kind  of  firm,  fleshy  tube,  formed  within  the  vessel,  with  a 
considerable  quantity  of  ossific  matter  dispersed  i^^-regularly 
through  it.  This  tube  did  not  appear  to  have  any  vascular 
connection  with  the  coats  of  the  artery,  but  seemed  to  lie 
merely  in  simple  contact  with  it. 

"  As  the  heart,  1  believe,  in  every  subject  that  has  died  of 
the  angina  pectoris,  has  been  found  extremely  loaded  with 
fat,  and  as  these  vessels  lie  quite  concealed  in  that  substance, 
is  it  possible  this  appearance  may  have  been  overlooked?  The 
importance  of  the  coronaries,  and  how  much  the  heart  must 
suffer  from  their  not  being  able  duly  to  perform  their  func- 
tions (we  can  not  be  surprised  at  the  painful  spasms),  is  a 


AS 


4  ANGINA  PECTORIS  AND  ALLIED  STATES. 

subject  I  need  not  enlarge  upon,  therefore  shall  just  remark 
that  it  is  possible  that  all  the  symptoms  may  arise  from  this 
one  circumstance. 

"  As  I  frequently  write  to  Mr.  H.  I  have  been  some  time 
in  hesitation  respecting  the  propriety  of  communicating  the 
matter  to  him,  and  should  be  exceedingly  thankful  to  you, 
sir,  for  your  advice  upon  the  subject.  Should  it  be  admitted 
that  this  is  the  cause  of  the  disease,  I  fear  the  medical  world 
may  seek  in  vain  for  a  remedy,  and  I  am  fearful  (if  Mr. 
Hunter  should  admit  this  to  be  the  cause  of  the  disease)  that 
it  may  deprive  him  of  the  hopes  of  a  recovery." 

In  another  letter  *  Jenner  gives  as  his  reasons  for  not  pub- 
lishing his  views  earlier  an  anxiety  lest  they  should  be  a  source 
of  annoyance  to  his  friend  Hunter.  "  Soon  after  Mr.  Paythe- 
rus  met  with  a  case.  Previous  to  our  examination  of  the  body 
I  offered  him  a  wager  that  we  should  find  the  coronary  arteries 
ossified.  This,  however,  proved  not  to  be  exactly  true;  but 
the  coats  of  the  arteries  were  hard.  ...  At  this  time  my 
valued  friend,  Mr.  John  Hunter,  began  to  have  the  symptoms 
of  angina  pectoris  too  strongly  marked  upon  him;  and  this 
circumstance  prevented  any  publication  of  my  ideas  on  the 
subject,  as  it  must  have  brought  on  an  unpleasant  conference 
between  Mr.  Hunter  and  me."  He  says  that  Mr.  Cline  and 
Mr.  Home  did  not  tiiink  much  of  his  views.  "  AVhen,  how- 
ever, Mr.  Hunter  died,  Mr.  Home  very  candidly  wrote  to  me, 
immediately  after  the  dissection,  to  tell  me  I  was  right." 

The  further  details  of  Hunter's  remarkable  case  are  always 
referred  to.  From  1785,  when  he  had  a  severe  illness,  the  at- 
tacks became  increasingly  frequent,  and  were  brought  on  par- 
ticularly by  exercise  and  by  worry  and  anger;  and,  indeed,  he 
was  accustomed  to  say  "  that  his  life  was  in  the  hands  of  any 


*  Parry.    An  Inquiry  into  the  Symptoms  and  Causes  of  the  Syncope 
Anginosa,  commonly  called  Angina  Pectoris,  1799. 


«*« 


HISTORY  OF  THE  KEOOGNITION  OP  ANGINA.  6 

rascal  who  chose  to  annoy  and  tease  him."  During  the  last 
few  years  of  his  life,  though  he  did  a  large  amount  of  work, 
the  attacks  seem  to  have  been  very  frequent,  and  would  come 
on  aftcH*  very  slight  exertion  and  while  he  was  operating.  As 
he  had  himself  predicted,  death  came  suddenly,  in  conse- 
quence of  a  fit  of  temper  at  a  meeting  of  the  governors  of  St. 
George's  Hospital,  October  16,  1793.  "When  contradicted 
flatly,  he  left  the  board  room  in  silent  rage,  and  in  the  next 
room  gave  a  deep  groan  and  fell  down  dead.  The  coronary 
arteries  were  found  to  be  converted  into  open  bony  tubes,  and 
the  aorta  was  dilated. 

Attempts  have  been  made  by  French  writers  to  claim  the 
priority  in  the  description  of  the  disease  for  Rougnon,  pro- 
fessor of  medicine  in  the  University  of  Besangon.  In  a  letter 
addressed  to  M.  Lorry,  dated  February  23, 1768,*  he  describes 
the  case  and  circumstances  of  the  death  of  a  Captain  Charles. 
The  patient  had  become  asthmatic,  and  on  walking  fast  had  a 
sort  of  suffocation.  Six  weeks  before  his  death  he  had  com- 
plained to  M.  Rougnon  of  "  une  gene  singuUere  sur  toute  le 
partie  anUrieure  de  lapoitrine  en  forme  depladrcm?'^  The 
attacks  evidently  occurred  with  great  suddenness,  and  disap- 
peared with  equal  abruptness.  The  chief  stress  is  laid  upon 
the  feeling  of  suffocation,  but  it  is  evident  that  associated  with 
it  there  was  pain  of  great  intensity;  "seulement  une  douleur 
gravative  dans  la  region  du  cosur,  lorsquHl  eprouvoit  ses  suf. 
focations^''  Captain  Charles  died  very  suddenly,  shortly  after 
dining  with  his  friends.  The  pericardium  was  fatty;  the 
heart  was  large ;  there  were  no  valvular  defects;  the  coronary 
veins  were  enlarged  "  prodigiously  "  ;  no  mention  was  made 
of  the  condition  of  the  coronary  arteries.  Rougnon  lays  stress 
upon  the  obstruction  in  the  lungs  and  excessive  ossification  of 


•  Ltttn  d  Jf.  Lorry  sur  une  maladie  nouvelle.    Besan9on,  1768. 


6 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


the  cartilages.  He  confesses,  however,  that  the  condition  was 
very  puzzling,  and  the  autopsy  not  at  all  satisfactory  to  his 
friends:  "Jf.  Charles  est  mort,  disoient-iUy parce  quHl  est 
mortP 

I  can  not  agree  with  Professor  Gairdner,  who  says  that 
"  there  was  no  trace  of  anything  like  a  clinical  description  of 
angina  pectoris  in  M.  Rougnon's  letter."  *  The  suddenness 
of  the  attacks,  the  pain  in  the  region  of  the  heart,  the  abrupt 
termination,  and  the  mode  of  death — during  exertion  after  a 
full  meal — favor  the  view  that  the  case  was  one  of  true  an- 
gina.   (Xote  A.) 

To  Morgagni,  not  Rougnon,  is  due  the  credit  of  the  first 
description  of  a  single  case.  Ir  the  splendid  section  on  aneu- 
rysm of  the  aorta,  he  describes  angina  pectoris  accurately  in 
Case  V,  referring  to  the  paroxysms,  the  pain,  the  difficulty  of 
breathing,  the  numbness  of  the  left  arm,  and  the  effect  of  exer- 
tion.   I  read  you  here  extracts  from  the  case. 

"A  lady,  forty-two  years  of  age,  who  for  a  long  time  had 
been  a  valetudinarian,  and  within  the  same  period,  on  using 
pretty  quick  exercise  of  body,  she  was  subject  to  attacks  of  vio- 
lent anguish  in  the  upper  part  of  the  chest  on  the  left  side,  ac- 
companied with  a  difficulty  of  breathing  and  numbness  of  the 
left  arm;  but  these  paroxysms  soon  subsided  when  she  ceased 
from  exertion.  In  these  circumstances,  but  with  cheerfulness 
of  mind,  she  undertook  a  journey  fron;  Venice,  purposing  to 
travel  along  the  continent,  when  she  was  seized  with  a  parox- 
ysm, and  died  on  the  spot.  I  examined  the  body  on  the  follow- 
ing day.  .  .  .  The  e'^rta  was  considerably  dilated  at  its  curva- 
ture; and,  in  places  through  its  whole  tract,  the  inner  surface 
was  unequal  and  ossified.  These  appearances  were  propagated 
into  the  arteria  innominata.  The  aortic  valves  were  indurated." 
He  remarks:  "The  delay  of  blood  in  the  aorta,  in  the  heart, 
in  the  pulmonary  vessels,  and  in  the  vena  cava,  would  occasion 


*  Lancd,  1891,  i,  p.  604. 


HISTORY  OF  THE  RECOGNITION  OP  ANGINA.  7 

the  symptoms  of  which  the  woman  complained  during  life; 
namely,  the  violent  uneasiness,  the  difficulty  of  breathing,  and 
the  numbness  of  the  arm." — (Cooke's  Morgagni.) 

There  are  those,  indeed,  who  regard  Seneca  as  the  first  to 
describe  the  affection,  in  the  remarkable  account  which  he 
gives  of  his  own  disorder.  "With  this  view  Forbes  and  Gaird- 
ner  agree,  but  Parry  and  Stokes  do  not.  I  quote  from  Parry 
the  following  translation  of  part  of  Seneca's  graphic  account: 
"  The  attack  is  very  short  and  like  a  storm.  It  usually  ends 
within  an  hour.  I  have  undergone  all  bodily  infirmities  and 
dangers;  but  none  appears  to  me  more  grievous.  Why  not? 
Because  to  have  any  other  malady  is  only  to  be  sick;  to  have 
this  is  to  be  dying."  Seneca  states,  too,  that  his  physicians 
called  the  disease  a  meditatio  mortis. 

The  literature  of  angina  pectoris  has  become  very  volumi- 
nous. English  writers  have  contributed  most  largely  to  the 
clinical  description  of  the  disease.  Perhaps  the  two  most 
valuable  articles  are  lectures  xxxvii  and  xxxviii  in  Latham's 
Clinical  Medicine^  which  you  will  find  in  vol.  i  of  the  New 
Sydenham  Society  edition  of  his  works;  and  Professor  Gaird- 
ner's  essay  in  Reynolds'  System  of  Medicine.  The  best  recent 
expositions  in  French  and  German  are  to  be  found  in  IIu- 
chard's  T  '*'e  clinique  des  maladies  du  cceiir,  second  edition, 
1893,  which  gives  a  most  exhaustive  account  of  the  various 
forms  of  angina,  and  O.  Rosenbach's  Die  Kra/nhheiten  des 
HerzenSy  1896.  I  pass  about  for  your  inspection  a  number  of 
the  monographs  and  journal  articles  which  I  have  collected 
on  the  subject.  Parry's  essay  has  become  very  scarce,  but  it 
is  in  all  the  larger  medical  libraries.  Rougnon's  Lettre,  pub- 
lished at  Besangon,  1768,  is  still  more  rare.  The  copy  in  the 
Surgeon-General's  Library  is  the  only  one  I  have  ever  seen. 
I  would  ask  you  to  look  at  the  first  part  at  least  of  these  fly 
leaves,  which  I  picked  up  in  an  old  book  shop  a  few  years  ago. 


8 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


It  is  a  letter  to  Dr.  Ileberden  from  a  man  who  signs  himself 
"  Unknown,"  descriptive  of  his  own  ease.  He  had  seen,  in 
the  Critical  Review^  an  extract  from  Ileberden's  original 
paper,  and,  recognizing  his  malady,  he  wrote  in  this  letter  one 
of  the  very  best  accounts  which  exists  in  the  literature.  It  is 
particularly  noticeable  for  two  things:  He  clearly  dissociated 
the  pain  of  the  attack  from  the  angor  or  mental  feature,  and 
he  first  made  use  of  the  now  hackneyed  phrase  describing  the 
latter  aspect  as  "  an  universal  pause  within  me  of  the  opera- 
tions of  K'ature."  Expecting  a  sudden  death,  he  left  orders 
that  Ileberden  should  examine  his  body.  Within  three  weeks 
from  the  writing  of  the  letter  the  dissection  was  made  by  Jolin 
Hunter. 

DsFixiTiox. — In  the  consideration  of  a  disease  it  is  well, 
if  possible,  to  start  with  a  clear  understanding,  or  at  least  some 
concise  statement,  of  its  nature,  and  of  the  characters  of  the 
manifestations  by  which  it  is  recognized.  AVitli  some  disorders 
this  is  a  very  easy  matter.  For  example,  insufficiency  of  the 
aortic  valves  is  a  clearly  defined  affection,  with,  it  is  true,  a 
diverse  aetiology,  a  varied  anatomical  picture  (from  a  trifling 
curl  of  the  edges  of  a  valve,  to  a  clean  shaving  of  a  segment 
from  the  aortic  ring) ;  but  with  all  its  variations  there  are  asso- 
ciated definite  sequences  and  well-characterized  signs. 


Angina  pectoris  is  not  a  disease,  but  a  syndrome  or  symp- 
tom group  (without  constant  aetiological  or  anatomical  founda- 
tions) associated  with  complex  conditions,  organic  or  func- 
tional, of  the  heart  and  aorta.  Pain  about  the  heart  of  an 
agonizing  character,  occurring  in  paroxysms,  is  the  dominant 
feature  of  all  varieties  of  the  syndrome.  Used  to  define 
paroxysmal  attacks  of  pain  in  the  chest — breast-pang — we  em- 
ploy the  term  generically,  qualifying  the  varieties  by  such 
names  as  true,  false,  hysterical,  and  voso-motor. 


'"\ 


HEART  PAIN. 


9 


Before  passing  to  the  diacussion  of  the  varieties  of  angina 
pectoris  let  me  refer  briefly  to  the  subject  of 

Heart  Pain. — Disturbance  of  sensation  is  a  most  incon- 
stant symptom  of  heart  disease;  the  gravest  affections  are 
often  painless;  the  most  trifling  may  present  the  features  of 
an  intense  neuralgia;  while  a  very  limited  lesion  may  have 
as  its  sole  manifestation  paroxysms  of  agonizing  pain. 

The  following  abnormal  cardiac  sensations  may  be  recog- 
nized : 

1.  Consciousness  of  the  heart's  action;  a  fluttering,  a  sense 
of  goneness,  the  indefinable  uneasiness  associated  with  palpita- 
tion, a  sense  of  tension  in  the  chest  with  gasping,  all  or  some 
of  which  are  common  phenomena  in  emotional  states,  in  indi- 
gestion, neurasthenia,  and  hysteria. 

2.  Pain — darting,  stabbing,  tearing  or  boring,  dull  and 
heavy,  or  acute  and  piercing,  steady  or  paroxysmal — varying 
in  grades  of  intensity  and  in  duration,  often  transient  and 
trifling,  as  in  dyspepsia  and  the  tobacco  habit,  more  enduring 
and  severe  in  hysteria  and  neurasthenia,  and  occurring  in 
paroxysms  of  an  agonizing,  intolerable  character  in  the  forms 
of  angina.  It  often  radiates  over  the  area  of  distribution  of 
certain  of  the  cervical  and  dorsal  nerves. 

3.  There  is  an  element  peculiar  to  certain  conditions  of  the 
heart,  often  associated  with,  but  which  can  not  itself  be  prop- 
erly characterized  as  pain — indeed,  the  patient  often  expressly 
states  that  it  is  not  of  the  nature  of  physical  pain — a  sense  of 
imminent  dissolution,  a  mental  anguish,  which  has  been  vari- 
ously expressed  by  patients  and  writers  as  a  pause  in  the  opera- 
tions of  ^Nature,  the  very  hand  of  death,  angor  ammi,  etc. 
This  it  is  which  constitutes  the  special  feature  in  a  majority 
of  the  cases  of  true  angina. 

Classification  of  the  Forms  of  Angina  Pectoris. — ^It 
may  seem  a  refinement  to  subdivide  and  sort  cases  of  a  disorder 

a 


r 


10 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


which  is  acknowledged  to  be  only  a  symptom,  or,  as  it  has  been 
expressed,  a  ncurosal  incident  of  cardio-vascular  disease;  but 
there  are  practical  advantages  which  far  outweigh  any  theo- 
retical objections — advantages  of  the  very  greatest  moment  in 
prognosis  and  in  treatment. 

Following  the  work  of  Ileberden,  Parry,  and  others,  there 
were  cases  reported  as  angina  which  did  not  belong  properly 
to  that  category,  and  the  disorder  was  confounded  with  cardiac 
asthma,  wiiich  we  now  term  cardiac  dyspnoea.  As  early  as 
1812  J.  Latham  read  a  paper  on  certain  symptoms  usually  but 
not  always  denoting  angina  pectoris  {Medical  Transactions, 
Royal  College  of  Physicians).  He  remarks  that  when  the  ex- 
tremities are  cold,  tho  countenance  is  bluish  or  purplish,  the 
pulse  is  rapid,  and  respiration  is  performed  with  difficulty  and 
in  an  upright  position  of  the  body,  the  practitioner  has  usually 
concluded  that  the  disease  is  angina  pectoris.  The  class  of 
cases  which  he  described  were  evidently  orthopncea  and  car- 
diac dyspnoea,  associated  chiefly  with  affections  of  the  abdo- 
men. He  calls  the  state  angina  notha,  spurious  angina,  the 
first  time,  so  far  as  I  am  aware,  that  the  term  was  used  in 
literature. 

Laennec  recognized  different  degrees  of  intensity  in  an- 
gina, stating  that  it  was  "  far  from  possessing  the  degree  of 
severity  attributed  to  it  by  many  authors,"  and  was  evidently 
aware  that  it  occurred  commonly  enough  without  indicating 
any  serious  disease  of  the  heart  or  large  vessels.  "  Angina 
pectoris,  in  a  slight  or  middling  degree,  is  extremely  common, 
and  exists  very  frequently  in  persons  who  have  no  organic 
affection  of  the  heart  or  large  vessels."  * 

By  far  the  most  important  contribution  to  the  recognition 
of  varieties  of  angina  pectoris  was  made  by  Walshe,  who,  in 


■Is 

■■"A: 

I 

I 


♦  Forbes's  edition  of  Laennec,  fourth  edition,  p.  650. 


L 


I 


FORMS  OF  ANGINA  PECTORIS. 


11 


his  text-book  on  Diseases  of  the  Hearty  described  a  pseudo- 
angina  pectoris,  occurring  particularly  in  women,  and  in  the 
subjects  of  hysteria,  spinal  irritation,  and  various  forms  of 
neuralgia. 

The  recognition  by  Beau,  Graves,  Stokes,  and  others  of  the 
relation  between  the  abuse  of  tobacco  and  attacks  of  angina  led 
to  the  separation  of  the  important  group  of  toxic  cases.  Other 
forms  of  pseudo-angina  which  are  described  are  those  depend- 
ent upon  reflex  causes,  and  the  vaso-motor  type  of  Xothnagel. 

In  any  long  series,  the  cases  of  angina  fall  into  two  groups: 
those  in  which  there  are  signs  of  lesion  of  the  heart  or  arteries, 
or  of  both,  and  those  in  which  all  symptoms  of  organic  disease 
are  absent.  This  was  the  important  division  recognized  by 
Forbes  into  organic  and  functional  angina — the  angina  pec- 
toris vera  and  the  angina  pectoris  notha — the  true  and  the 
pseudo-angina. 

In  looking  over  the  cases  which  form  the  basis  of  these  lec- 
tures, I  find  that  they  fall  into  the  following  groups:  (1)  An- 
gina pectoris  vera,  and  (2)  angina  pectoris  notha,  under  which 
are  grouped  hysterical,  vasomotor,  and  toxic  forms. 

The  Coronary  Arteries. — A  few  essential  points  in  the 
anatomy  and  physiology  of  the  heart  may  here  engage  our  at- 
tention for  a  few  minutes.  The  coronary  arteries  are  the 
Abana  and  Pharpar  of  the  vascular  rivers,  "  lucid  streams," 
which  water  the  very  citadel  of  life.  By  means  of  these  in- 
jected specimens,  which  I  pass  around,  you  may  refresh  your 
memories  on  their  distribution.  The  arteries  are,  as  you  see, 
large  in  proportion  to  the  size  of  the  organ  to  be  nourished. 
From  the  position  of  their  origin  it  is  evident  that  they  must 
be  subject  to  blood  pressure  during  both  systole  and  diastole. 
The  left  coronary  is  usually  the  larger,  and  divides  into  two 
main  branches:  the  circumflex  or  posterior,  which  runs  in  the 
groove  between  the  left  ventricle  and  auricle,  and  the  anterior 


la 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


or  descending  ramus.  Note  particularly  the  branches  of  the 
latter  vessel,  which  runs  in  the  anterior  interventricular 
groove.  You  will  see  a  very  large  branch,  which  is  given  off 
to  the  anterior  wall  of  the  left  ventricle,  and  several  branches 
which  pass  deeply  into  the  septum.  This  anterior  branch  is 
the  important  one  in  the  morbid  anatomy  of  the  coronary 
arteries,  since  it  is  by  far  the  most  frequently  found  the  seat 
of  extensive  sclerosis  or  of  embolism  or  thrombosis.  It  may 
be  called  the  artery  of  sudden  death. 

From  the  date  of  Sir  John  Eric  Erichsen's  observations  on 
the  subject  (1842)  to  the  present  the  effects  of  closure  of  the 
coronary  arteries  have  been  much  discussed.  A  very  good  his- 
torical summary  is  given  by  W.  T.  Porter  in  the  Journal  of 
Physiology,  vol  xv,  1893.  It  is  remarkable  how  discordant  are 
the  statements  of  different  observers.  As  this  author  remarks, 
seldom  have  the  results  of  physiological  studies  been  more  at 
variance;  there  is  no  statement  which  is  not  denied,  no  fact 
which  is  not  disputed.  More  recently  Porter  has  again  gone 
over  the  whole  question  with  a  great  deal  of  skill,  and  I  will 
give  you  here  some  of  his  conclusions.* 

The  frequency  of  the  stoppage  of  the  heart's  action  is  in 
proportion  to  the  size  of  the  artery  tied.  Ligation  of  the  small- 
est artery,  the  arteria  scpti,  does  not  cause  arrest;  of  the  next 
in  size,  the  coronaria  dextra,  fourteen  per  cent,  of  the  ligations 
were  followed  by  arrest;  then  comes  the  larger  descendens 
wiih  twenty-eight  per  cent. ;  and,  finally,  the  circumflex,  the 
largest  artery  of  all,  with  sixty-four  per  cent. 

The  effect  of  closure  of  the  coronary  arteries  on  the  blood 
pressure  within  the  heart  is  of  great  importance.  After  the 
tying  of  a  single  vessel  there  is  a  diastolic  rise  of  pressure, 
which  is  not  compensated  for  by  any  increase  of  pressure  in 

♦  Journal  of  Experimental  Medicine,  vol.  i,  No.  1, 1896. 


A 


THE  CORONARY  ARTERIES. 


13 


the  coronary  arteries;  on  the  contrary,  in  them  the  pressure 
is  falling,  while  that  in  the  auricles  is  rising.  It  is  known  that 
the  normal  mean  pressure  in  the  auricles,  and  consequently 
in  the  coronary  veins  near  their  mouths,  is  very  low.  A  rise 
of  a  few  millimetres  of  auricular  pressure  might  interrupt  the 
entire  coronary  circulation.  This  is  one  of  the  most  impor- 
tant points  brought  out  by  Porter's  researches,  and  I  quote 
here  a  paragraph  on  this  point:  "  It  must  be  acknowledged, 
then,  that  a  rising  auricular  pressure  after  ligation  may  at 
length  put  a  stop  to  the  whole  blood  supply  of  the  cardiac  mus- 
cle, and,  as  this  rise  is  often  occasioned  by  the  closure  of  a 
single  vessel,  it  is  plain  that  the  entire  coronary  circulation 
can,  in  fact,  be  interrupted  by  the  ligation  of  one  coronary 
artery." 

It  has  been  much  debated  whether  the  coronary  arteries 
are  really  temiinal  or  end  arteries.  Anatomically,  it  may  be 
shown  that  they  are  not,  since  an  injection  liquid  can  be  made 
to  pass  from  one  artery  through  communicating  branches  into 
the  other.  All  are  agreed,  however,  that  the  anastomosis  is 
not  sufficient  to  permit  collateral  circulation  to  keep  a  vascular 
area  alive  after  the  distributing  artery  is  blocked.  The  effect 
of  plugging  of  the  artery  is  the  production  of  what  is  known  as 
an  anaemic  infarct,  a  well-recognized  pathological  condition, 
the  consideration  of  which  need  not  detain  us.  A  very  impor- 
tant matter  relates  to  the  effect  of  plugging  of  the  coronary 
arteries  upon  the  heart-beat;  the  contractions  become  of  the 
type  known  as  fibrillary,  and  it  is  difficult  or  impossible  to  get 
the  organ  to  resume  the  ordinary  co-ordinated  beats,  though 
experimentally  this  has  been  done,  even  after  fibrillary  con- 
traction has  been  established. 

The  relation  of  coronary-artery  disease  to  angina  pectoris, 
which  was  suggested  by  Jenner,  has  directed  the  very  particu- 
lar attention  of  writers  to  the  changes  in  these  vessels.    It  does 


14 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


one  good  to  look  over  tlie  older  literature,  and  to  note  the  ac- 
curacy with  which  sonic  of  the  cases  have  been  recorded,  par- 
ticularly by  Morgagni.  Parry,  too,  gives  an  interesting  series 
from  the  older  writers.  The  subject  is  so  extensive  that  I  can 
not  enter  upon  it  here  in  great  detail,  but  I  may,  perhaps, 
bring  it  before  you  with  sutHcient  emphai5is  if  I  speak  of  the 
common  sequences  in  connection  with  illustrative  cases. 

The  coroniuy  arteries  are  very  subject  to  degenerative 
changes,  particularly  in  persons  who  have  passed  the  middle 
period  of  life.  They  may  l)e  affected  alone  or  as  part  of  a  wide- 
spread disease  of  the  vessels.  For  practical  purposes  we  need 
not  consider  any  other  change  than  arterio-sclerosis  in  its  vari- 
ous grades,  from  a  trifling  thickening  to  atheroma  and  rigid 
calcification.  We  must,  however,  recognize  an  affection  of  the 
orifices  of  the  ai'teries,  apart  from  the  common  degeneration 
of  the  trunks.  A  gradual  narrowing  of  the  orifice  of  a  vessel 
may  be  quite  as  serious  as  extensive  disease  of  the  branches. 
There  is  a  form  of  aortitis  met  with  not  infrequently  in  men 
between  the  ages  of  thirty  and  forty,  who  have  had  syphilis 
and  who  have  worked  hard  and  drank  deep  {devotees  of 
Venus,  Bacchus,  and  Vulcan),  in  which  the  intima  is  swollen, 
almost  corrugated,  with  fresh  translucent  areas  of  endarteritis. 
I  skip  all  considerations  of  its  anatomy.  Three  serious  se- 
quences may  follow:  {a)  Rupture  of  the  aorta,  sometimes 
only  of  the  intima,  as  clean  cut  as  with  a  razor,  in  half  or  a 
third  of  the  circumference,  sometimes  with  the  formation  of 
a  dissecting  aneurysm;  {h)  the  slow  development  of  the  ordi- 
nary form  of  aneurysm  of  the  arch ;  and  {c)  narrowing  of  the 
orifices  of  the  coronary  arteries.  Angina  attacks,  sudden 
death,  and  slowly  developing  myocarditis  and  its  sequences  are 
the  possibilities  in  this  third  category.  I  pass  around  this  fine 
plate  of  Corrigan's,  taken  from  the  Dnhlin  Journal^  in  which 
you  see  great  swelling  of  the  intima  above  the  valves,  due,  as 


% 

V 


M 


'**t'(i 


THE  CORONA IIY  ARTERIES. 


15 


Corrigan  expressed  it,  "  to  an  eflfusion  of  organized  lymph  be- 
tween the  lining  niemlinnic  and  the  fibrous  coat."  The  pa- 
tient in  this  case,  a  man  only  thirty-nine  years  of  age,  suffered 
with  severe  attacks  of  angina. 

Let  me  illustrate  by  these  specimens  some  of  the  more  com- 
mon pathological  conditions  associated  with  disease  of  the 
branches  of  the  artery.  Here  is  an  extraordinary  heart,  which 
illustrates  how  much  of  the  coronary  circulation  can  be  cut  off 
if  the  obstruction  takes  place  gradually.  The  organ  was  taken 
from  a  man  aged  about  thirty-six  or  thirty-seven,  who  had 
been  an  inmate  for  eighteen  years  of  the  lastitution  for 
Feeble-minded  Children  at  Elwyn,  Pa.  He  was  a  large, 
powerful  imbecile,  dumb  but  not  deaf.  He  was  very  good 
tempered,  did  a  great  deal  of  work  about  the  farm,  and  fre- 
quently did  very  heavy  lifting.  He  never  had  epilepsy;  he 
was  not  known  to  be  short  of  breath,  nor  had  he  complained 
or  indicated  in  any  way  that  he  was  out  of  health.  One 
after^ioon  he  had  a  sort  of  fit,  the  face  became  very  much  con- 
gested, and  he  died  in  about  half  an  hour.  There  was  nothing 
special  found  in  the  brain.  The  heart,  as  you  see,  is  large,  and 
weighed  twenty  ounces.  There  was  general  hypertrophy  with 
dilatation.  There  was  quite  extensive  fibroid  myocarditis, 
particularly  in  the  anterior  wall  of  the  left  ventricle,  at  the 
apex,  and  in  the  lower  portion  of  the  septum  ventriculonim ; 
the  valves  were  normal.  But  what  I  wish  you  to  examine 
most  particularly  is  the  state  of  the  coronary  arteries,  which 
are  freely  dissected  out.  The  left  vessel  is  almost  obliterated, 
only  a  pin-point  channel  remaining,  while  of  the  right  artery 
the  main  division  passing  between  the  auricle  and  ventricle  is 
converted  into  a  fibroid  cord ! 

It  is  much  more  common  to  find  one  artery  extensively  dis- 
eased, or  even  completely  obliterated.  Take,  lor  example,  this 
specimen,  which  was  removed  from  a  colored  man,  aged  about 


fc    i 


k 


I    4 


IQ  ANGINA  PECTORIS  AND  ALLIED  STATES. 

thirty-five,  who  had  aortic  insufficiency,  with  dyspnoea  and 
oedema  of  the  legs.  He  died  suddenly,  though  he  had  for 
some  weeks  great  dilatation  of  the  heart  and  general  anasarca. 
The  aortic  segments  are  curled  and  thickened;  the  ascending 
arch  is  greatly  deformed,  with  a  recent  general  endarteritis. 
There  are  a  few  calcareous  plates.  The  right  coronary  artery 
is  completely  obliterated.  There  is  no  opening  whatever  on 
the  aorta.  The  left  vessel  is  dilated,  and  presents  atheroma- 
tous, patches.  There  are  areas  of  fibrous  myocarditis  in  the  left 
ventricle,  but  in  other  respects  the  muscular  substance  of  the 
heart  does  not  look  abnormal,  and  it  is  not  fatty. 

Here  is  a  much  more  common  condition.  In  this  anterior 
coronary  artery  you  see  a  firmly  adherent  thrombus,  which 
completely  occludes  the  descending  branch,  to  the  lumen  of 
which  it  is  firmly  attached.  It  was  taken  from  a  man  about 
fifty  years  of  age,  who  had  mitral-valve  disease  and  had  a  good 
deal  of  cardiac  dyspnoea.  Early  one  morning  he  was  seized 
with  severe  pain  about  the  heart  and  shortness  of  breath,  and 
died  in  a  very  few  moments.  Both  coronary  arteries  were 
thickened  and  calcified,  and  presented  atheromatous  plates, 
but  no  doubt  the  sudden  death  was  due  to  the  blocking  of  the 
anterior  branch  of  the  left  coronary  artery  by  the  thrombus. 

AVhen  the  occlusion  has  persisted  for  any  length  of  time 
before  death  the  condition  of  anaemic  necrosis  may  be  found. 
I  am  sorry  not  to  have  a  fresh  specimen  to  show  you,  but  most 
of  you  have,  no  doubt,  seen  microscopic,  if  not  macroscopic, 
examples.  It  is  important  in  the  dissection  of  the  heart  to 
slice  carefully  the  septum  and  the  wall,  as  these  infarcts  of  the 
heart  muscle  are  found  in  numbers  directly  proportionate  to 
the  care  with  which  they  are  sought.  We  have  not  had  any 
very  large  number  of  cases.  They  are  much  more  common,  I 
think,  in  hospitals  with  old  chronic  cases,  or  with  which  there 
are  in  connection  large  almshouses,  as  at  the  Blockley  Hospi- 


THE  CORONARY  ARTERIES. 


17 


icea  and 

had  for 

inasarca. 

scending 

arteritis. 

y  artery 

tever  on 

;heroma- 

i  the  left 

;e  of  the 

anterior 

3,  which 

umen  of 

in  about 

d  a  good 

as  seized 

'ath,  and 

ies  were 

s  plates, 

M 

ig  of  the 

'onibus. 

of  time 

e  found. 

but  most 

roscopic, 

heart  to 

M 

•ts  of  the 

M 

lonate  to 

had  any 

mmon,  I 

!ch  there 

y  Ilospi- 

tal.  I  was  much  impressed  at  that  institution  with  the  num- 
ber of  cases  of  anaemic  infarcts — many  more  than  I  saw  at  the 
Montreal  General  Hospital  or  have  seen  here.  They  occur 
most  frequently  in  the  walls  of  the  left  ventricle  and  in  the 
septum,  particularly  toward  the  apex.  When  fresh  they 
stand  out  beyond  the  level  of  the  surrounding  muscle,  and  are 
sometimes  very  firm,  yellowish  white,  or  even  quite  opaque 
white  in  color.  With  the  fresh  infarcts  there  may  be  old 
fibroid  patches,  into  which  ultimately  these  areas  of  anaemic 
necrosis  are  transformed. 

To  complete  the  series,  I  show  you  here  sections  of  the  de- 
scending branch  of  the  left  coronary  artery,  which  you  see  is 
almost  completely  obliterated  by  an  old,  much-altered  throm- 
bus. This  case  illustrates  another  sequence  of  slowly  develop- 
ing coronary  artery  disease — namely,  fibroid  myocarditis  at 
the  apex,  with  weakening  of  the  wall,  and  the  gradual  forma- 
tion of  aneurysm  of  the  heart.  The  specimen  was  taken  from 
the  body  of  a  large,  powerfully  built  man  whose  heart  symp- 
toms developed  with  great  abruptness,  and  who  presented  for 
many  months  an  obscure  train  of  symptoms  pointing  to  serious 
disease  of  the  myocardium. 

Autopsies  on  cases  of  angina  pectoris  are  not  common. 
The  man  with  a  fresh  thrombus  in  the  anterior  branch  of  the 
left  coronary  artery  probably  died  in  a  paroxysm  of  angina, 
but  he  had  not  had  previous  typical  attacks.  As  I  will  tell  you 
lateT"  '^n,  the  affection  is  rare  in  hospital  practice  so  that  we  do 
not  have  opportunities  of  making  the  inspection  of  the  bodies 
of  persons  who  have  died  of  the  disease. 

And,  lastly,  a  few  words  on  the  innervation  of  the  hearty  a 
cardinal  point,  inasmuch  as  the  very  essence  of  the  angina  par- 
oxysm must  rest  on  some  profound  disturbance  in  the  function 
of  the  nerves.  The  newer  methods  of  investigation  have  added 
considerably  to  our  knowledge  of  the  distribution  of  the  in- 


18 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


trinsic  nerves  of  the  organ.  Doubtless  some  of  you  have  seen 
in  the  pathological  laboratory  Dr.  Berkeley's  wonderful  speci- 
mens illustrating  the  ultimate  terminations  of  the  filaments 
between  and  on  the  fibres.*  In  looking  at  them  one  realizes 
the  truth  of  the  remark  of  a  recent  author,  that  it  is  difficult 
to  say  in  which  the  myocardium  is  richer,  nerve  elements  or 
muscle  fibres.  Everywhere  throughout  the  organ — in  the  tis- 
sues beneath  the  endocardium  and  pericardium,  throughout 
the  muscle  substance,  and  about  the  blood-vessels — the  nerves 
are  in  extraordinary  profusion.  The  double  nen'e  supply  you 
know,  from  vagus  and  sympathetic,  and  the  double  function, 
the  fonner  controlling,  checking,  and  inhibiting,  the  latter 
augmenting  the  force  and  hastening  the  fre(piency  of  the 
heart-beats.  The  researches  of  His  junior  and  Romberg  have 
shown  that  the  ganglion  cells  of  the  heart,  even  those  lying  in 
the  vagus  branches,  have  the  same  origin  as  all  other  sympa- 
thetic cells.  They  differ  in  protoplasmic  appearances  and  in 
other  %vays  from  the  cells  of  the  spinal  ganglia.  The  rhythmic 
action  of  the  heart  is  probably  automatic,  due  to  a  power  in- 
herent in  the  muscular  fibres,  though  this  point  is  still  in  dis- 
pute. Of  the  functions  of  the  nerves  we  know  a  good  deal,  of 
the  functions  of  the  ganglia  nothing.  His  and  Romberg  sug- 
gest that  from  them  are  transmitted  to  the  central  nen^ous  sys- 
tem infinitely  delicately  graded,  unconscious  imp'ilscs,  which 
regulate  the  circulation  reflexly  through  the  vagus  and  accel- 
erator. Of  Kronecker's  co-ordination  centre  our  knowledge 
is  still  very  indefinite — indeed,  its  existence  has  been  called  in 
question.  I  have  seen  Kronecker  perform  the  experiment, 
and  certainly  when  the  point  in  the  dog's  heart  is  pricked — it 
is  situated  about  the  lower  limit  of  the  upper  third  of  the  ven- 
tricular septum — the  organ  becomes  paralyzed  in  a  state  of 
fibrillary  tremor,  from  which  it  does  not  recover.    This  point 

*  Described  in  Johna  Hopkins  Hospital  Reports,  vol.  iv. 


,-.# 


THE  CORONARY  ARTERIES. 


19 


is  within  the  area  of  distribution  of  the  anterior  coronary 
artery,  the  vessel  oftenest  found  plugged  by  thrombus  or  em- 
bolus in  cases  of  sudden  death. 

Do  these  cardiac  nerves  possess  other  properties?  Have 
they  also,  with  the  special  function,  the  endowment  of  receiv- 
ing tactile  and  painful  impressions?  Certainly  the  heart  is  not 
an  organ  of  very  acute  sensibility.  The  most  extensive  lesions, 
inflammatory,  degenerative,  and  neoplastic,  may  not  excite  a 
single  painful  sensation.  Pericarditis  of  the  most  intense 
grade,  with  deep  involvement  of  the  myocardium,  may  give 
not  the  slightest  indication  of  its  existence. 

In  experimental  work,  pinching  of  the  heart  muscle  may 
excite  reflex  movements  of  the  muscles  of  the  body.  There  are 
a  few  interesting  cases  in  the  human  subject  in  which  the  heart 
has  been  exposed  by  accident  sufficiently  to  enable  it  to  be 
grasped  or  touched.  In  the  well-known,  case  which  Harvey 
gives  *  of  the  young  Viscount  de  Montgomery,  in  whom 
Charles  I  was  so  much  interested,  in  consequence  of  a  fracture 
of  the  ribs  on  the  left  side,  with  excessive  suppuration,  the 
heart  was  exposed,  and  from  Harvey's  account  was  quite  insen- 
sitive: "  Nempe,  in  homine  vivente  et  vegeto,  citra  ullam 
offensam,  cor  sese  vibrans,  ventriculosque  ejus  pulsantes  vi- 
deret,  as  manu  tangeret.  Factumque  est,  ut  serenissimus  Rex, 
una  mecum,  cor  sensu  tactus  privatum  esse  agnoscerejt. 
Quippe  adolescens,  nos  ipsum  tangere  (nisi  visu,  aut  cutis  ex- 
terioris  sensatione)  neutiquam  intelligebat." 

There  is  one  other  point  of  great  importance.  Sensory- 
nerve  endings  have  been  demonstrated  in  the  arteries  by 
Thoma,  and  recently  Smimow  f  professes  to  have  demon- 
strated similar  structures  in  the  connective  tissues  of  the  heart, 
he  thinks  the  sensory-nerve  beginnings  of  the  depressor  nerve. 


*  Exercitatioties  de  generatione  animalium,  1651,  p.  311, 
f  Anatomischer  Anzeiger,  1895. 


LECTUKE  n. 


I  I 


I  I 


ANGINA   PECTORIS   VERA. 
ETIOLOGY.     GENERAL  DESCRIPTION  OP  THE  DISEASE. 

Incidence  of  the  disease.— Station  in  life.— Sex.— Age.— Epidemic  influences. 
-Heredity.— Gout.— Diabetes.— Syphilis.— Specific  fevers.— Heart  dis- 
ease.— Locomotor  ataxia. — General  picture  of  the  disease. 

Incidence  of  the  Disease. — As  noted  long  ago  by  Sir 
Gilbert  Blaine,  angina  pectoris  is  a  rare  affection  in  hospital 
practice.  Gairdner  criticises  this  statement  rather  sharply,  and 
yet  I  think  that  a  majority  of  hospital  physicians  would  be 
found  to  support  it.  During  the  ten  years  in  which  I  lived  in 
Montreal,  I  did  not  see  a  case  of  the  disease  either  in  private 
practice  or  at  the  Montreal  General  Hospital.  At  Blockley 
(Philadelphia  Hospital),  too,  it  was  an  exceedingly  rare  affec- 
tion. I  do  not  remember  to  have  had  a  case  under  my  per- 
sonal care.  There  were  two  cases  in  my  service  at  the  Univer- 
sity Hospital.  During  the  seven  years  in  which  the  Johns 
Hopkins  Hospital  has  been  opened,  with  an  unusually  large 
"  material "  in  diseases  of  the  heart  and  arteries,  and  with 
many  cases  of  heart  pain  of  various  sorts,  there  have  been 
only  four  instances  of  angina  pectoris.  You  will  find  the 
statement  in  Fagge's  Practice  (third  edition,  vol.  ii,  p.  26) 
that  "  the  writer  has  never  seen  classical  angina  in  hospital 
practice." 

On  the  other  hand,  an  individual  consultant  may  see  within 

a  year  more  cases  than  occur  in  all  the  hospitals  of  his  town 

80 


% 


ANGINA  PECTORIS  VERA. 


21 


within  the  same  period.  In  corroboration  of  this  striking  con- 
trast between  the  incidence  of  angina  pectoris  in  hospital  and 
consulting  work  I  may  refer  to  the  statistics  of  the  Edinburgh 
Royal  Infirmary,  in  which  for  the  two  years  covered  by  the 
JlospitalJieportSjlSOS  and  1894,  there  were  five  cases  among 
a  total  of  8,8G8  medical  cases.  Compare  with  this  the  personal 
experience  of  the  distinguished  Edinburgh  consultant.  Dr. 
Balfour,  who,  in  his  recently  issued  work  on  The  Senile  Heart, 
gives  an  analysis  of  ninety-eight  cases  of  angina  pectoris  seen 
within  ten  years.  My  individual  experience  embraces  a  series 
of  sixty  cases,  forty  of  which  may  be  regarded  as  true  an- 
gina. 

The  predisposing  causes  of  angina  pectoris  vera  are  those  of 
arterio-sclerosis;  that  is  to  say,  so  intimately  associated  is  the 
true  paroxysm  with  sclerotic  conditions  of  the  coronary  ar- 
teries that  it  is  extremely  rare  apart  from  them.  Men  of  mus- 
cular, even  athletic  build,  who  have  been  devotees  of  Bacchus 
and  of  Venus,  form  perhaps  the  largest  contingent.  Gout, 
syphilis,  and  hereditary  influence  the  causation  only  so  far  as 
they  tend  to  cause  sclerotic  changes  in  the  arteries;  but  it 
would  be  altogether  too  narrow  a  view  to  suppose  that  the 
{Etiology  of  the  disease  is  identical  with  that  of  arterio-sclero- 
sis. The  one  is  so  common  and  the  other  comparatively  rare 
even  among  the  individuals  most  prone  to  sclerosis,  that  there 
must  be  a  third  element,  an  indefinite  something,  which  yet 
escapes  our  knowledge,  but  which  is  the  essential  factor  in  the 
production  of  this  terrible  affliction. 

Station  in  Life. — As  Sir  John  Forbes  remarks,  it  is  an  at- 
tendant rather  of  ease  and  luxury  than  of  temperance  and 
labor;  on  which  account,  though  occurring  among  the  poor, 
it  is  more  frequently  met  with  among  the  rich,  or  in  persons 
of  easy  circumstances.  It  is  remarkable  how  many  prominent 
individuals  have  succumbed  to  the  disease.    "We  may  say  of  it 


22 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


l! 


as  Sydenham  did  of  the  gout,  that  more  wise  men  than  fools 

are  its  victims. 

I  do  not  know  that  any  special  occupation  or  profession 
predisposes  to  it,  but  the  frequency  with  which  physicians  are 
attacked  has  been  commented  upon  by  several  writers.  In  my 
list  of  sixty  cases  of  all  forms,  there  were  thirteen  medical  men, 
eight  of  whom  had  true  angina.  This  percentage  is  doubtless 
exceptional,  and  due,  in  part  at  least,  to  my  nomadic  habits, 
and  wide  acquaintance  in  the  profession. 

Sex. — From  the  earliest  description  of  the  disease,  the  re- 
markable preponderance  of  males  who  are  attacked  has  been 
noted.  Heberden  says:  "  I  have  seen  neai'ly  one  hundred 
people  under  this  disorder,  of  which  number  there  have  been 
three  women  "  {Commentaries).  The  statistics  collected  by 
Huchard  give  in  two  hundred  and  thirty-seven  cases  of  true 
angina  only  forty-two  in  women.  In  my  own  series  of  forty 
cases  of  true  angina  there  was  only  one  woman. 

Age. — The  age  at  which  it  is  most  common  is  that  of  ar- 
terio-sclerosis — after  the  fiftieth  year  of  life.  Of  the  forty 
cases  on  my  list  there  were  only  four  under  the  fortieth  year. 
One  of  these,  a  man,  aged  thirty  years,  had  had  syphilis  five 
years  before;  the  other  case,  a  woman,  aged  thirty-two  years, 
had  mitral-valve  disease;  the  third  case  had  terrible  attacks 
of  angina  following  chronic  pleurisy.  In  the  fifth  decade 
there  were  thirteen;  in  the  sixth,  thirteen;  in  the  seventh, 
rme;  and  of  one  case  I  did  not  get  the  exact  age.  The  aver- 
■  r^Q  of  the  thirty-nine  cases  was  about  fifty-three  years.  Cases 
;uc'  reported  in  quite  young  individuals,  even  in  children,  but 
such  are  almost  invariably  the  subject  of  chronic  valvular  dis- 
ease or  of  adherent  pericardium. 

Epidemic,  Ijiitative,  and  Emotional  Influences. — 
La(  nee  was  "  of  the  opinion  that  the  prevalent  type  of  disease 
influences  its  development,"  and  adds,  "  I  have  some  years  met 


ANGINA  PECTORIS  VERA. 


23 


i 


with  it  frequently,  and  hardly  at  all  in  others."  You  will  find 
reference  in  the  literature  to  so-called  outbreaks  of  angina 
which  have  been  reported  by  Kleefeld  *  and  by  Gelineau.f  I 
can  not  see  that  the  cases  recorded  by  Kleefeld  have  anything 
to  do  with  angina  pectoris.  He  describes  the  epidemic  as  a  re- 
mittent fever  with  gastric  complications,  and  much  pain  about 
the  heart.  Some  of  the  cases  were  fatal,  but  tic  autopsies  were 
made.  Young  persons,  chiefly  women  and  children,  were 
attacked. 

Gelineau,  surgeon  to  the  French  corvette  L'Embuscade, 
reports  a  remarkable  outbreak  among  the  sailors  during  a  pro- 
longed cruise  in  the  Pacific.  Scurvy  had  broken  out  and  the 
men  were  much  debilitated  and  anaemic.  They  became  sub- 
ject also  to  a  severe  dry  colic.  Following  this  there  were  many 
cases  of  angina.  The  first  case  was  that  of  an  old  sailor,  scor- 
butic and  anaemic,  who  while  climbing  the  mast  was  seized 
with  intense  pain  about  the  heart.  Five  days  after,  five  other 
men  were  attacked  in  the  same  sudden  way,  and  three  days 
later,  three  more.  Gelineau  lays  a  good  deal  of  stress  upon 
tobacco  as  a  factor  in  the  causation  of  the  pain,  and  also  upon 
the  debility  following  the  scurvy,  dysentery,  and  dry  colic. 
The  effect  of  imitation,  that  extraordinary  occult  influence  so 
potent  in  many  forms  of  hysteria,  must,  no  doubt,  be  taken 
into  account.  Perhaps  the  most  notable  instance  is  given  by 
Dr.  Taber  Johnson  in  his  report  of  Mr.  Sumner's  case.*  "  I 
have  observed  a  curious  fact,  which  it  may  be  interesting  to 
refer  to  here.  I  mean  the  unusual  number  of  patients  suffer- 
ing from  this  disease,  who,  previous  to  Mr.  Sumner's  severe 
illness,  had  never  supposed  that  they  had  any  disease  of  the 
heart.     This  fact  has  been  referred  to  by  newspaper  corre- 

*  Journal  d.  praet.  Heilkunde,  1823,  Ivii. 

f  Gazette  den  ffopitaux,  1862,  xxxv. 

X  Boston  Medical  and  Surgical  Journal,  1874. 


i 


u 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


spondents — viz.,  that  during  the  illness  of  Mr.  Sumner,  and 
especially  since  his  death,  instances  of  its  occurrence  have 
considerably  increased,  and  especially  among  those  who 
strongly  sympathized  with  the  late  senator.  This  seemingly 
sympathetic  cause  of  disease  has  been  noticed  in  other  cases. 
I  have  been  consulted  by  as  many  as  thirty  individuals,  since 
Mr.  Sumner's  death,  who  imagined  they  were  afflicted  with 
his  complaint.  In  some  of  these  cases  there  was  organic  dis- 
ease of  the  heart,  but  in  a  majority  of  them  there  was  no 
cardiac  trouble  at  all.  Two  weeks  after  the  autopsy  in  Mr. 
Sumner's  case,  one  of  the  physicians  who  assisted,  a  devot- 
edly attached  friend  of  the  deceased,  died  of  angina  pectoris. 
I  am  informed  that  Dr.  Hitchcock  had  but  a  few  attacks,  and 
that,  prior  to  Mr.  Sumner's  death,  he  had  never  been  a  suf- 
ferer from  angina  pectoris." 

Dr.  Johnson  says  that  he  himself  suffered  from  two  attacks 
very  closely  resembling,  if  they  were  not  really,  angina.  One 
of  these  occurred  immediately  after  Mr.  Sumner's  death,  and 
Brown-Sequard,  who  was  present,  said  the  phenomena  were 
undoubtedly  those  of  a  paroxysm  of  angina.  Twenty-two 
years  have  passed,  and,  happily  for  himself,  as  well  as  for  our 
brethren  of  the  District  of  Columbia,  Dr.  Taber  Johnson  has 
now  less  mobile  nerves. 

In  Case  X  of  my  series  of  pseudo-angina  the  patient's  hus- 
band died  suddenly  in  a  paroxysm  of  true  angina. 

Mental  worry,  severe  grief,  or  a  sudden  shock  may  precede 
directly  the  onset  of  the  attacks.  In  Case  XXXVI,  the  parox- 
ysms came  on  after  the  shock  of  the  announcement  that  a  son 
had  committed  suicide. 

Heredity. — True  angina  pectoris  is  an  arterial  incident, 
and  since  the  members  of  certain  families  show  a  special  tend- 
ency to  arterial  degeneration,  it  -is  not  surprising  to  find  cases 
in  father  and  son,  or  in  brothers,  or  even  in  representatives  of 


ANGINA  PECTORIS  VERA. 


26 


three  generations.  Tliere  are  remarkable  instances  on  record. 
The  first,  and  one  of  the  most  remarkable,  is  that  reported 
by  Dr.  Robert  Hamilton,*  in  which  the  father  of  the  patient, 
a  young  man  aged  twenty-four,  two  brothers,  and  one  sister 
were  affected.  In  all,  the  disease  developed  in  early  life;  in 
Hamilton's  own  patient,  at  the  twelfth  year.  It  is  quite  pos- 
sible from  his  description  that  the  disease  may  not  have  been 
angina  pectoris,  but  spasmodic  asthma  associated  with  heart 
pain. 

The  best-known  instance  is  that  of  the  Arnold  family.  Wil- 
liam Arnold,  collector  of  customs  of  Cowes,  died  suddenly  of 
spasm  of  the  heart  in  1801.  His  son,  the  celebrated  Thomas 
Arnold,  of  Rugby,  whose  case  I  will  narrate  to  you  shortly, 
died  in  his  first  attack.  Matthew  Arnold,  his  distinguished  son, 
was  a  victim  of  the  disease  for  several  years,  and  died  suddenly 
in  an  attack  on  Sunday,  April  15,  1888,  having  been  spared, 
as  he  hopes  in  his  little  poem  called  A  Wish — 

"  the  whispering,  crowded  room, 
The  friends  who  come,  and  gape,  and  go; 
The  ceremonious  air  of  gloom — 

All,  which  makes  death  a  hideous  show! " 

At  the  time  of  his  death,  the  accounts  which  appeared  in 
the  Lancet  and  British  Medical  Journal  were  not  clear 
as  to  the  existence  of  attacks  of  angina.  The  various 
stages  in  the  progress  of  his  illness  can  be  traced  very 
well  in  his  Letter s,\  in  which  you  will  find  an  account  of 
numerous  attacks  from  May,  1885,  until  the  time  of  his 
death.    (:N'ote  B.) 

In  looking  over  the  literature  one  finds  occasional  refer- 
ences to  cases  occurring  in  several  members  of  one  family. 


*  Medical  Commentaries,  1785,  ix. 

f  Letters  of  Matthew  Arnold,    Macmillan  &  Co.,  1896. 

8 


26 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


Cazanave  de  la  Roclie  *  records  three  cases  in  one  family — a 
sister,  who  was  affected  at  the  time  of  the  report,  and  two 
brothers  who  had  died  of  the  disease.  In  Case  XXIII  on  my 
list  the  patient's  father  died  of  angina  pectoris. 

Gout. — The  relation  of  certain  constitutional  disorders  to 
angina  pectoris  has  been  much  discussed.  The  importance  of 
gout  as  a  factor  was  early  suggested,  and  in  this  interesting 
little  monograph  of  Butter's,  which  I  show  you  here — the  first 
separate  treatise  on  the  disease — the  author  places  the  scat  of 
the  disorder  in  the  diaphragm,  and  calls  it  diaphragmatic 
gout.    The  affection  has  also  been  termed  asthma  arthriticum. 

Nathaniel  Chapman  advocated  strongly  the  arthritic  na- 
tui  of  angina  pectoris,  and  there  can  be  no  question,  I  think, 
that  in  a  certain  number  of  the  victims  gout  plays  an  impor- 
tant role  in  inducing  the  arterio-sclerosis. 

I  have  been  particularly  interested  in  examining  into  this 
point  in  the  cases  which  have  come  under  my  observation 
within  the  past  four  or  five  years.  There  are  four  cases  at 
least  of  my  series  in  which  gout  seemed  to  play  a  part.    Dr. 

,  of  Virginia,  seen  April  3,  1894,  a  very  robust,  vigorous 

man  of  forty-eight,  temperate,  a  hard  worker,  who  had  not  had 
syphilis,  and  in  whom  the  attacks  were  fairly  characteristic, 
thinks  that  gout  (which  is  in  his  family)  is  directly  responsible 
for  the  attacks.  Certainly,  after  using  without  benefit  for 
many  months  the  iodides  and  the  nitrites,  he  obtained  the 
greatest  relief  from  a  prolonged  course  of  colchicum.  It  is 
now  more  than  two  years  since  I  saw  him,  and  he  remains 
well.  In  another  case,  a  patient  with  attacks  of  angina  pectoris 
sine  dolore,  there  had  been  attacks  of  acute  articular  gout. 
In  a  third  case,  a  man  aged  sixty-four,  the  upper  half 
of  the  pinna  of  the  lobe  of  the  right  ear  was  firm  and  calcified, 


La  Tribune  midicah,  1895,  p.  832. 


{•V, 


ANGINA  PECTORIS  VERA. 


27 


and  the  same  process  was  beginning  in  the  left  ear.  Thero 
were  no  tophi,  but  the  calcification  was,  to  say  the  least,  sug- 
gestive. A  fourth  case  was  that  of  a  physician  from  North 
Carolina,  aged  forty-six,  who  had  for  many  years  attacks 
of  gouty  arthritis,  chiefly  in  the  big  toe,  less  frequently  in  the 
ankles.    There  was  a  well-marked  tophus  in  the  right  ear. 

Diabetes. — The  association  of  angina  pectoris  with  dia- 
betes has  been  frequently  noted.  No  instance  has  fallen 
under  my  personal  observation.  You  will  find  the  whole  sub- 
ject very  thoroughly  discussed  by  Ebstein  in  a  recent  paper 
in  the  Berliner  klinische  Wochenschrift  of  last  year  (1895). 

Syphilis  is  one  of  the  potent  factors  in  inducing  arterio- 
sclerosis, and  thus  indirectly  plays  a  role  in  angina  pectoris. 
Of  the  cases  in  my  series,  only  four  gave  a  history  of  syphilis. 
The  instances  of  aortitis  to  which  I  have  already  referred,  oc- 
curring in  the  third  and  fourth  decades  in  men  who  have  had 
syphilis,  have  worked  hard,  and  have  been  heavy  drinkers,  are 
sometimes  associated  with  severe  attacks  of  angina.  In  Case  I, 
Lieutenant  X.,  aged  thirty  years,  a  robust,  powerful  man,  had 
had  syphilis  six  years  before  his  visit  to  me.  The  secondary 
symptoms  were  slight,  and  he  had  not  had  very  thorough  treat- 
ment. A  year  before  I  saw  him  he  began  to  have  severe  pains 
in  the  heart,  recurring  in  paroxysms,  and  associated  with  pain 
down  the  left  arm,  and  dyspnoea  on  exertion.  There  was  no 
perceptible  enlargement  of  the  heart;  there  was  a  systolic 
murmur  at  the  apex  and  a  soft  bruit  at  the  aortic  area,  with- 
out special  accentuation  of  the  aortic  second  sound.  The  at- 
tacks had  been  of  such  severity  that  he  had  been  off  duty  for 
many  months.  He  improved  very  much  upon  the  iodide  of 
potassium,  but  siill  had  attacks  six  months  after  I  saw  him, 
since  which  time  I  have  not  heard  of  him.  Corrigan's  case, 
you  remember,  the  illustrative  plate  of  which  I  showed  you 
at  the  last  lecture,  was  in  a  young  man,  and  belonged  to  this 


28 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


group.  The  frontiHpicce  in  Balfour's  work  on  the  heart  (sec- 
ond edition)  ilhistrates  another  case  of  the  same  kind  in  a  still 
younger  man,  aged  twenty-four  yeai-s.  The  angina  attacks 
were  associated  with  an  aortitis  which  narrowed  greatly  the 
orifices  of  the  coronary  arteries. 

Si'KCiKic  Fkvkks. — In  connection  with  the  specific  fevers 
several  writers  have  described  angina-like  attacks.  Fraentzel, 
iti  his  Vodesunyen  iiher  die  Krankheiten  des  Jlersens  (Berlin, 
1889),  describes  attacks  of  angina  pectoris  In  the  weakened 
and  dilated  heart  following  the  infections,  particularly  ery- 
sipelas, typhoid  fever,  and  pneumonia.  J.  VV.  Moore  *  has  re- 
ported two  instances  of  angina  symptoms  in  connection  with 
heart  weakness  during  and  after  the  specific  fevers.  In  the 
epidemic  of  a  remittent  fever  reported  by  Kleefeld  (and  al- 
ready referred  to)  the  attacks  of  heart  pain  may  have  been  of 
this  cliaracter.  I  do  not  remember  to  have  seen  a  case  in 
which  the  attack  developed  during  convalescence  from  one 
of  the  ordinary  fevers. 

Among  the  many  nervous  sequels  of  influenza,  {c\v  are 
more  distressing  than  the  attacks  of  severe  cardiac  pain.  In 
some  cases,  indeed,  the  disease  seems  to  have  boon  the  starting 
point  of  attacks  of  true  angina.  The  frequency  of  the  compli- 
cation in  the  practices  of  some  physicians  is  remarkable.  In 
a  paper  on  The  Action  of  Influenza  Poison  on  the  Heart,  Cur- 
tin  and  Watson  state  that  within  two  years  they  met  with 
fully  seventy  cases  of  painful  attacks  about  the  heart.  The  il- 
lustrative cases  in  their  paper  f  show  that  some  of  the  attacks 
must  have  been  of  very  great  severity,  but,  in  most  instances, 
the  duration  of  the  disease  was  short  and  the  cases  evidently 
belonged  to  the  category  of  pseudo-angina.    I  have  seen  but 


*  Dublin  Medical  Journal,  1890,  vol.  Ixxxix. 

f  International  Medical  Magazine,  January,  1893. 


ANGINA  PECTORIS  VERA. 


S9 


two  inatnnpcs  in  whioh  the  attack  seemed  to  follow  directly 
upon  the  influenza.  One  is  certainly  pseudo-angina;  the  other 
proved  to  be  the  genuine  disease. 


I  saw  on  several  occasions  in  Toronto  a  medical  friend  who, 
after  a  tolerably  severe  attack  of  influenza  about  three  years  ago, 
began  to  have  attacks  of  agonizing  pain  about  the  heart.  They 
came  on  without  warning,  the  pain  appearing  in  various  parts 
of  the  chest,  commonly  under  both  shoulder  blades,  and  espe- 
cially severe  in  both  wrists.  There  was  at  first  no  irregularity 
of  the  pulse  or  difficulty  in  breathing;  but  in  some  attacks  there 
wcic  piping  rales  during  expiration.  At  first  these  attacks  were 
almost  nightly;  several  times  they  ended  in  vomiting  (preceded 
by  profuse  salivation),  the  passage  of  more  or  less  flatus,  and 
copious  sweating.  There  was  no  mental  anxiety  whatever,  ex- 
cept, as  he  expressed  it,  "  the  pain  was  so  intense  that  I  was 
afraid  I  would  recover,  in  order  to  endure  it  again."  The  pain 
in  the  arms  was  chiefly  in  the  front  of  the  wrists.  The  patient 
had  not  had  any  serious  illness  previously,  had  never  had  syphi- 
lis, had  not  been  a  heavy  drinker,  but  had  been  a  pretty  heavy 
smoker.  The  attacks  recurred  with  intensity  throughout  the 
early  part  of  January.  When  I  saw  him  there  were  no  signs  of 
cardiac  disease.  He  had  had  a  good  deal  of  digestive  disturb- 
ance. During  the  following  summer  and  autumn  he  progres- 
sively improved,  and  I  heard  from  him  recently  to  the  effect 
that  now  only  in  any  extra  strain,  an  in  the  attendance  upon  a 
difficult  case  of  labor,  does  he  feel  any  pain.  He  used  the  iodide 
steadily  for  some  time  without  any  special  benefit.  He  at- 
tributes more  benefit  to  lavage  of  the  stomach  with  hot 
water  night  and  morning.  How  far  the  influenza  in  this  case 
was  responsible  for  the  attack  is,  of  course,  difficult  to  say,  but 
when  I  saw  him  first  he  was  very  insistent  that  it  was  the  cause  of 
his  whole  trouble.  From  the  rapid  way  in  which  the  attacks 
have  ameliorated  and  his  present  general  condition  there  is, 
to  say  the  least,  a  strong  probability  that  it  is  functional  and 
not  associated  with  organic  disease. 

The  other  case  was  that  of  the  late  chief  justice  of  this  State, 
who  had,  in  the  early  winter  of  1893,  a  very  severe  attack  of 


J  I 


X\!         I 


'  i^ 


30 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


i    I 


influenza  with  much  fever  and  prostration.  In  the  latter  part 
of  December  he  began  to  have  pain  about  the  heart  in  walking 
briskly  up  a  hill.  Then  he  had  more  severe  attacks,  but  in  the 
summer  of  189i  he  was  better,  and  was  able  to  take  long  walks. 
Tin  attacks  recurred  about  Christmas,  1894.  I  saw  him  on 
January  20,  1895.  There  was  no  enlargement  of  the  heart, 
tbe  sounds  were  clear,  the  second  aortic  a  little  accentuated. 
The  only  striking  anomaly  was  a  condition  of  trigeminal  heart- 
beats— groups  of  three  beats,  with  an  interval,  followed  in  regu- 
lar sequence.  He  improved  very  much  through  the  summer 
of  1895.  In  October  he  had  a  severe  shock  on  hearing  of  the 
sudden  death  fror.i  angina  of  his  brother-in-law  (Case  XXXV 
on  my  list).  He  did  not,  however,  have  any  recurrence  until 
December.  I  saw  him  on  January  5,  189G.  The  paroxysms 
had  become  more  frequent  and  very  severe.  In  the  following 
week  he  died  in  an  unusually  prolonged  attack.  The  onset  of 
the  angina  corresponded  with  the  period  of  convalescence  from 
the  influenza,  which  he  always  insisted  had  caused  the  attacks. 

Heart  Disease. — Paroxysms  of  agonizing  substernal 
pain,  with  radiation  to  the  neck  and  ann,  are  rare  in  the  ordi- 
nary forms  of  heart  disease  which  we  meet  with  in  hospital 
work.  II'?art  pain  is  connnon  enough,  and  if  we  counted  all 
such  cases  as  angina  we  would  not  have  to  lay  stress  on  the  in- 
frequence  of  this  syndrome  in  the  wards.  You  remember  the 
small  boy  in  Ward  F  during  the  early  part  of  this  session,  with 
greatly  enlarged  heart,  probably  from  pericardial  adhesions. 
Pran  was  the  most  distressing  symptom  of  the  case,  but  it  had 
neither  the  intensity,  the  paroxysmal  character,  nor  the  ac- 
companiments which  warrant  the  diagnosis  of  true  angina. 
So,  too,  in  the  case  of  the  old  colored  woman,  at  present  in 
Ward  O,  with  mitral-valve  disease  and  extreme  artcrio-sclcro- 
p's.  I  have  pointed  out  to  you  that  the  attacks  of  sudden 
breathlessness  and  distress  with  transient  pain,  are  of  the  na- 
ture of  cardiac  asthma,  with  which,  as  I  will  tell  you  later, 
angina  pectoris  is  often  confounded.    Then,  again,  you  have 


I 


ANGINA  PECTORIS  VEEA. 


31 


to  bear  in  mind  the  common  complaint  of  pain  beneath  the 
left  breast  in  patients  with  chlorosis  and  various  forms  of 
anaimia. 

Of  valvular  affections,  aortic  insufficiency  is  that  with 
which  angina  pectoris  is  most  frequently  associated.  Of  the 
forty  cases  in  my  list  three  presented  signs  of  this  lesion.  The 
subjects  of  the  degenerative  type  of  the  disease,  which  de- 
velops in  men  after  the  fortieth  year,  are  much  more  prone  to 
angina  than  those  in  whom  the  insufficiency  has  followed  en- 
docarditis. The  younger  the  subject,  the  greater  the  proba- 
bility that  the  incompetency  results  from  an  acute  aortitis, 
as  in  Corrigan's  case,  to  which  I  have  referred  on  several  occa- 
sions. 

Angina  pectoris  is  excessively  rare  in  mitral-valve  disease. 
This  is  well  illustrated  by  Nothnagel's  experience.*  Of  fifteen 
hundred  cases  of  valvular  disease  of  the  heart  seen  in  hospital 
and  private  practice,  very  many  of  which  had  symptoms  of  an- 
gina, there  was  but  a  single  case  in  which  the  syndrome  oc- 
curred in  connection  with  mitral  stenosis.  Only  one  of  my 
cases,  a  woman,  had  a  mitral  lesion.  By  far  the  most  common 
heart  disease  with  which  angina  is  associated  is  chronic  myo- 
carditis, the  signs  of  which  are  often  dubious. 

Cases  of  adherent  pericardium  and  of  aneurysm  of  the 
aortic  arch  may  present  the  features  of  typical  angina,  more 
often,  in  my  experience,  of  constant  substernal  pain  or  of 
cervico-brachial  neuralgia. 

A  mr jority  of  the  subjects  of  angina  present  the  signs  of 
arterio-fclerosis,  with  accentuation  of  the  aortic  second  sound 
and  slight  increase  in  the  area  of  transverse  heart  dullness. 
Some  of  the  most  rapidly  fatal  cases  are  those  in  which  the 
physical  signs  are  very  sligltt,  or  even  absent.    Of  the  cases  on 


■■■■  y 


Sl 


i      % 


Verhandlungen  dea  Congresses  f.  innere  Jledicin,  Bd.  x. 


32 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


i    'i 


my  list,  in  four  only  was  the  physical  examination  negative; 
three  presented  apical  or  basic  murmurs;  of  the  remainder, 
all  of  whom  showed  signs  of  sclerosis  of  the  arteries,  nine  had 
indications  of  myocardial  changes. 

Locomotor  Ataxia. — Considering  the  close  relationship 
of  syphilis  to  this  disease,  in  which  also  arterio-sclerosis  is  so 
common,  it  is  not  surprising  that  attacks  of  angina  pectoris 
should  occur.  No  instance  has  fallen  under  my  personal  ob- 
servation. You  know  that  aortic  insufficiency  is  not  rare  in 
tabes.  At  Blockley  the  association  was  a  matter  of  every-day 
comment,  and  in  the  physical-diagnosis  class  we  would  send  to 
the  out  wards  for  the  old  tabetics  to  demonstrate  the  lesions  of 
arterio-sclerosis,  and  if  not  of  aortic  incompetency,  of  the  ring- 
ing metallic  aortic  second  sound,  which  so  often  accompanied 
the  dilated  and  rigid  aortic  arch.  You  will  find  the  subject 
fully  discussed  by  Leyden  in  the  Zeitschrift  f.  klin.  Iledicin 
for  1887,  and  since  his  paper  there  have  been  several  less  im- 
portant communications. 

General  Picture  of  the  Disease. — In  any  long  series  of 
cases  of  angina  we  can  recognize  four  groups: 

T,  Sudden  Death,  without  other  Manifestations  of  Angina 
Pectoris. — Much  more  true  of  angina  pectoris  is  what  Andral 
said  of  the  fulminant  form  of  cholera:  it  begins  where  other 
diseases  end—  "n  death.  The  affection  has  indeed  been  called 
by  Sir  Walter  Foster  a  mode  of  death,  which  reminds  one  of 
the  expression  of  the  physicians  who  spoke  of  Seneca's  malady 
as  a  meditatio  mortis.  Xo  inconsiderable  proportion  of  sudden 
deaths  in  men  of  middle  age  and  robust  habits  rosult  from 
coronary-artery  disease,  from  the  rapid  culmination,  so  to 
speak,  of  a  condition  which,  in  another  (or  on  previous  occa- 
sions in  the  individual  himself),  would  have  caused  an  ordi- 
nary attack  of  angina.  Before  all  is  over  there  may  be  a  mo- 
mentary conscious  agony  expressed  by  a  cry,  but  in  other  in- 


i 


ANGINA  PECTORIS  VERA. 


83 


stances  (and  this  is  most  frequently  the  ease  in  the  subjects  of 
angina)  the  death  is  literally  instantaneous;  more  rapid,  per- 
haps, than  that  which  occurs  by  any  other  mode. 

Of  the  fifteen  deaths  in  my  series,  eight  took  place  sudden- 
ly; in  five,  gradually  by  cardiac  asystole;  in  one,  I  did  not 
learn  the  exact  mode  of  death ;  in  another,  the  patient  died  of 
obstruction  of  the  bowels.  Of  the  eight  cases,  in  five  death 
was  sudden,  almost  without  warning,  and  not  in  a  paroxysm 
p+'  angina. 

>ir.  S.  (Case  XXVI)  died  on  his  doorstep;  Mr.  W.  (Case 
XXVII)  died  as  he  was  leaving  a  friend's  house;  Dr.  X.  (Case 
VIII)  died  as  he  was  walking  from  one  room  to  another.  He 
had  had  cardiac  arrhythmia,  Cheyne-Stokes  breathing,  and 
marked  mental  disturbance;  Mr.  E.  (Case  XXXV)  died  in- 
stantly on  the  edge  of  the  bed  as  he  was  recovering  from  his 
first  attack  of  angina,  not  having  had  pains  for  nearly  twenty- 
four  hours;  Mr.  R.  (Case  XI)  fell  over  dead  on  attempting  to 
get  out  of  bed.  The  literature  abounds  in  cases  of  this  sort, 
and  the  proportion  of  the  victims  of  angina  who  die  abniptly 
is  muc'  !a!jj,'^r  than  my  figures  indicate.  Forbes  mentions 
that  '  f  •  ;.  '-.four  cases  sudden  death  occurred  in  forty-nine. 
Anatomicti  1;  n  has  been  shown  that  lesion  of  the  coronary 
arteries  is  almost  invariably  present — either  extensive  arterio- 
sch  iosis,  embolism,  thrombosis,  or  in  rare  instances  the  burst- 
ing of  a  small  athertjinatous  abscess  in  one  vessel,  such  as  killed 
the  celebrated  sculptor  Thorwaldsen.*  An  explanation  of  the 
awful  suddenness — "  Life  struck  sharp  on  Death  " — is  prob- 
ably 1  >  be  found  in  the  arrest  of  the  heart  in  fibrillary  con- 
tract r  R  uli  as  takes  ])lace  experimentally  in  animals  after 
ligation  of  a  coronary  vessel. 

II.  Death  in  the  First  ^^^eU-mar'Tced  Paroxysm., — A  man 


I 


III 


:-   s 


m 


*  Virchow's  Archiv,  Bd.  xxv. 


11^ 


j  f 


3i 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


in  full  health,  in  the  prime  of  life,  may  be  seized  with  a  parox- 
ysm of  angina,  and  die  within  a  few  hours.  The  cases  in  this 
category  are  not  numerous.  Perhaps  the  most  remarkable  one 
on  record,  which  has  become  quite  historic,  is  that  of  the  cele- 
brated Dr.  Arnold,  of  Rugby,  who  in  the  words  of  his  distin- 
guished son  (also  a  victim  of  the  disease),  arose 

"...    :>  ■^TP'^d 
In  the  summer  mor^         'he  road 
Of  death,  at  a  call  unfui^seen, 
Sudden." 


II 


■ 


The  following  is  Latham's  account:  * 

"T.  A.  was  within  a  day  of  completing  his  forty-seventh 
year.  Up  to  a  few  hours  before  his  death,  both  body  and  mind 
seemed  equally  to  give  proof  and  promise  of  health,  lie  still 
took  his  accustomed  pleasure  and  refreshment  in  strenuous 
exercise.  His  thoughts  were  still  busily  employed  upon  the 
highest  subjects,  conceiving  and  composing  with  wonderful 
ease,  rapidity,  and  power.  He  retired  to  rest  at  midnight  on  the 
11th  of  June,  1842,  feeling  and  believing  himself  to  be  in  per- 
fect health.  At  a  quarter  before  seven  the  next  morning  his 
medical  attendant  was  called.  What  had  previously  occurred 
and  what  followed  I  will  give  in  the  words  of  Dr.  Bucknill,  who 
was  with  him  during  the  short  remaining  period  of  his  exist- 
ence. *  On  my  entering  his  room  he  said  that  he  was  sorry  to 
disturb  me  so  soon;  and  that  ho  had  not  sent  for  me  before, 
thinking  that  it  would  go  off.  He  added,  "I  have  had  very 
severe  pain  in  the  chest  since  five  o'clock,  at  intervals,  and  it 
gets  worse,  I  think."  This  pain  was  seated  at  the  u])per  part 
of  the  chest,  toward  the  left  side,  and  extended  down  tlie  left 
arm.  He  had  been  rather  sick.  He  then  asked  mo  what  the 
pain  was.  "  What  is  it?  "  He  was  now  almost  free  from  pain. 
His  pulse  I  coiild  scarcely  feel.    The  tongue  was  clean.    There 

The  feet  and  legs  were 


was  cold  perspiration  over  his  face. 


*  Latham's  Works,  vol.  i,  p.  453 ;  Now  Sydenham  Society,  1876. 
also  Stanley's  Life  of  Thomas  Arnold. 


See 


ANGINA  PECTORIS  VERA. 


35 


cool.  The  breathing  at  this  time  not  troubled.  I  gave  him 
immediately  some  hot,  strong  brandy  and  water,  and  having 
ordered  a  mustard  plaster  for  his  chest,  till  this  was  ready  I 
applied  hot  flannels,  and  had  his  legs  and  arms  rubbed  and  the 
feet  wrapped  up  in  flannels  wrung  out  of  hot  water  and  mus- 
tard. The  pulse  became  natural,  the  extremities  more  warm, 
and  he  was  free  from  pain.  The  mustard  plaster  was  brought  and 
put  on.  It  was  not  large  enough  and  I  ordered  another.  The 
pain  then  returning,  I  gave  him  more  brandy  and  water,  and  it 
soon  left  him.  And  now  he  asked  me  again  what  the  pain  was. 
I  told  him  I  believed  it  was  spasm  of  the  heart.  He  exclaimed, 
"Ah!"  I  asked  him  whether  he  had  ever  fainted  in  his  life. 
"  No,  never."  If  he  had  at  any  time  difficulty  of  breathing. 
"  No,  never."  If  any  pain  in  his  chest  before.  "  No,  never." 
I  then  asked  him  if  any  of  his  family  had  ever  had  any  disease 
of  the  chest.  "  Yes,  my  father  had;  he  died  of  it."  He  in- 
quired if  disease  of  the  heart  was  suddenly  fatal.  I  answered 
that  it  was.  "  Was  it  a  common  disease  ?  "  I  said  not  very  com- 
mon. "Where  do  you  find  it  most?"  "In  large  towns,  I 
think."  "  Why?  "  "  Perhaps  from  anxiety  and  eager  com- 
petition among  the  higher,  and  intemperance  among  the  lower 
classes."  He  was  then  quiet  and  free  from  pain,  and  I  proposed 
to  leave  him  for  a  minute  or  two.  He  had  no  pain  whatever 
in  my  absence.  On  my  return  the  perspiration  was  still  in  drops 
upon  his  forehead.  The  pulse  was  again  feeble,  and  I  gave 
him  more  brandy  and  water  and  had  the  flannels  with  mustard 
renewed.  An  attack  of  pain  was  coming  on.  He  said,  "  I  must 
stretch  myself."  I  took  one  of  his  hands  and  held  it  until  the 
pain  was  gone  off.  It  was  of  short  duration.  I  said,  "  Is  it 
gone?"  He  answered,  "Yes,  entirely,"  adding  that  he  "could 
scarcely  bear  it  if  it  were  as  severe  as  it  had  been."  ITc  then 
asked  me  "  what  was  the  general  cause  of  this  kind  of  disease." 
He  then  said,  "  Is  this  likely  to  return?  "  I  answered  that  I 
was  afraid  it  was,  but  that,  as  the  attacks  had  been  less  severe 
and  less  frequent,  I  hoped  they  would  pass  off.  He  next  asked 
me  if  the  disease  was  generally  suddenly  fatal.  I  said  generally 
(for  those  who  knew  him  were  aware  that  it  was  impossible  not 
to  tell  him  the  exact  truth).    I  then  asked  him  if  he  had  any 


i'1.1 


3G 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


pain.  He  said,  "  None  but  from  the  blister;  one  can  bear  out- 
ward pain,  but  it  is  not  so  easy  to  bear  inward  pain."  I  was 
now  dropping  some  laudanum  into  a  wineglass,  when  he  in- 
quired what  I  was  going  to  give  him.  I  told  him  laudanum, 
Hoffman's  anodyne,  and  camphor;  and,  while  I  was  preparing 
the  mixture,  and  before  I  had  finished,  1  heard  a  rattling  in  the 
throat  and  a  convulsive  struggle.  I  called  out,  and  on  turning 
to  him  I  sup[)orted  his  head,  which  was  thrown  back  on  my 
shoulder.  His  eyes  were  fixed  and  his  teeth  set,  and  he  was 
insensible.  His  breathing  was  very  laborious,  his  chest  heaved, 
and  there  was  a  severe  struggle  over  the  upper  part  of  the  body. 
His  pulse  was  imperceptible,  and  after  deep  breathings  at  a 
few  prolonged  intervals  all  was  over.  He  died  in  little  more 
than  half  an  hour  after  I  first  saw  him.' " 

The  examination  showed  a  soft,  flaccid  heart  muscle.  There 
was  but  one  coronary  artery,  and  that,  considering  the  size  of 
the  heart,  of  small  dimensions.  It  presented  also  a  slight  athe- 
romatous deposit  an  inch  from  its  orifice. 


In  no  case  in  my  series  did  death  occur  in  the  first  parox- 
ysm. The  most  rapid  case  was  'Mr.  E.  (Case  XXXV),  who 
had  an  agonizing  paroxysm  at  2.30  r.  m.  on  October  14th, 
and  several  lesser  recurrences  throughout  the  night.  There 
was  no  attack  on  the  ISth,  and  he  passed  a  comfortable  night. 
On  the  IGth,  at  9.10  a.  m.,  he  sat  up  on  the  edge  of  the  bed 
to  be  helped  to  the  commode,  and  fell  over  dead,  about  forty- 
two  hours  from  the  onset  of  the  first  attack. 

III.  Hecurring  Attacks  extending  over  a  Period  of  Months 
or  Years. — Much  more  commonly  a  victim  of  angina  pectoris 
has  many  paroxysms  over  a  period  of  many  months,  or  from 
three  or  four  to  twenty  or  even  twenty-five  years.  The  re- 
currences may  be  at  long  intervals,  as  in  John  Hunter's  case, 
or  they  may  render  the  patient's  life  unbearable,  since  he  feels 
that  the  slightest  transgression,  muscular  or  emotional,  may 
precipitate  a  paroxysm.  Many  a  poor  sufferer  has  felt  what 
Senator  Sumner  expressed:    "  This  treacherous  disease  pro- 


ANGINA  PECTORIS  VERA. 


37 


duces  in  my  mind  a  positive  uncertainty,  when  I  go  out  of 
my  house,  whether  I  sliall  ever  enter  it  again  a  hving  man, 
and,  with  the  pain  I  have  to  suffer,  makes  my  life  such  a  bur- 
den that  the  sooner  it  does  its  work  the  better  I  shall  be 
pleased.  Life,  at  the  price  I  have  to  pay,  is  not  worth  the  hav- 
ing." Let  me  read  you  the  history  of  a  typical  case  of  this 
sort: 

Case  XXVL — Mr,  S.,  an  editor  by  occupation,  aged  fifty- 
five,  consulted  me  January  10,  1894,  complaining  of  attacks 
of  agonizing  pain  in  the  region  of  the  heart.  The  patient  was 
of  a  nervous  temperament,  but  had  been  a  very  healthy  man. 
He  had  never  done  hard  physical  work  and  had  been  moderate 
in  the  use  of  alcohol  and  tobacco.  lie  did  not  think  that  he 
had  ever  had  sypliilis.  Three  years  ago,  following  upon  the 
shock  of  the  announcement  of  the  suicide  of  a  son,  he.  had  his 
first  attack  of  severe  pain  about  the  heart.  Ever  since,  the  at- 
tacks have  recurred  at  irregular  intervals,  at  first  of  a  few  weeks 
or  a  month,  but  within  the  past  year  they  have  been  very  fre- 
quent, so  that  he  now  rarely  passes  a  day  without  paroxysms. 
They  vary  a  great  deal  in  intensity.  If  he  walks  fast  or  makes 
any  unusual  exertion  he  is  stopped  by  an  intense  pain  in  the 
heart,  and  he  has  to  pant  for  breath.  After  lasting  for  half  a 
minute  or  so  the  pain  passes  off,  and  he  is  able  to  resume  his 
walk.  Any  unusual  emotion  or  excitement  will  bring  on  an 
attack  at  once.  lie  not  uncommonly  now  has  as  many  as  a 
dozen  or  more  attacks  in  the  day.  In  the  severer  paroxysms 
he  feels  as  if  the  throat  was  greatly  swollen,  and  says  that  both 
his  throat  and  his  temples  throb,  and  tnat  he  gets  very  red  in 
the  face.  As  the  attacks  pass  off  he  usually  sweats  quite  pro- 
fusely. From  what  I  can  gather,  he  did  not  appear  to  have  had 
paroxysms  of  terrible  agony,  in  which  the  sense  of  impending 
death  was  present.  He  says,  however,  that  the  feeling  is  as 
though  the  heart  was  grasped  in  a  vice,  and  the  pains  shoot  up 
the  neck  and  down  the  left  arm.  Two  weeks  ago,  in  Philadel- 
phia, while  walking  to  the  station,  he  felt  an  excessively  severe 
pain  in  the  chest,  became  short  of  breath,  and  fell  unconscious. 
When  he  recovered  he  found  himself  in  a  neighboring  chemist's 


i, 


11 


i^^ 


i 

1 

■v 

1 

1 

38 


ANGINA  PECTORIS  AxVD  ALLIED  STATES. 


shop.  He  was  able,  however,  to  proceed  on  his  journey.  While 
in  my  waiting  room  this  patient  had  two  attacks,  and  while 
I  was  examining  him  he  had  a  third,  the  phenomena  of  which 
I  will  describe  to  you  later.  Three  days  after  his  visit  to  me, 
while  walking  up  the  steps  of  his  house,  he  dropped  dead. 

The  great  majority  of  all  cases  of  angina  pectoris  come  in 
this  group. 

lY.  Rapidly  Repeated  Attacks  over  a  PeHod  of  Days  or 
Weeks,  with  the  Development  of  a  State  of  Cardiac  Asystole 
— Vetat  de  mat  anginenx. — An  individual  in  apparently  good 
health,  who  may  not  have  had  any  indications  of  heart  trouble, 
or  who  may  have  had  at  some  previous  date  an  attack  of  an- 
gina, is  seized  with  a  severe  paroxysm.  This  passes  away,  but 
there  is  shortly  a  recurrence,  and  for  several  days  in  rapid  suc- 
cession there  are  subintrant  attacks,  with  increasing  weakness 
of  the  heart.  Huchard  describes  the  condition  as  Vetat  de 
mat  angineux.  In  a  way,  it  is  a  counterpart  of  the  status  epi- 
lepticus.  The  condition  is  one  of  terrible  distress.  I  have 
seen  but  two  cases,  and  as  this  feature  of  the  disease  has  not 
been  specially  dwelt  upon  by  writers,  except  Huchard,  I  will 
read  you  an  account  of  them  both. 

Case  XXXII.— On  January  3,  1894,  I  saw  with  Dr.  Pole, 
Mr.  L.,  aged  fifty-five  years,  merchant,  who  for  a  week  had  had 
attacks  of  severe  pain  in  the  region  of  the  heart. 

The  patient  was  a  stout,  large-framed  man,  who  had  lived 
for  many  years  a  life  of  great  activity.  He  had  always  enjoyed 
very  excollont  health;  never  had  had  rheumatism.  He  has 
seven  healthy  children.  He  had  been  a  moderate  smoker  and 
moderate  drinker,  chiefly  of  beer.  He  had  not  had  syphilis. 
Seven  years  ago,  after  a  slight  exertion,  he  had  a  very  severe 
attack  of  pain  about  the  heart,  which  lasted,  however,  only  a 
day  and  then  passed  off.  He  had  no  recurrence  and  had  been 
very  well,  though,  occasionally,  he  has  been  a  little  short  of 


ANGINA  PECTORIS  VERA. 


39 


breath  on  walking  rapidly.  A  week  ago,  December  S7th,  a  fire 
occurred  in  his  place  of  business,  and  he  was  naturally  very 
much  excited,  and  helped  to  save  the  papers  and  books.  That 
night  he  had  a  severe  attack  of  angina  pectoris,  accompanied 
with  vomiting  and  sweating.  He  was  better  the  next  day  and 
able  to  go  out.  Since  then  he  has  had  three  attacks,  all  of  tliera 
of  a  good  deal  of  severity.  He  feels  very  weak  and  feeble  and 
the  pains  are  severe  enough  to  require  morphine.  Last  night 
they  were  very  much  worse. 

He  was  a  well-nourished,  healthy-looking  man.  The  pulse 
was  about  90,  and  there  was  no  increase  in  tension;  the  radials 
were  not  sclerotic,  and  though  the  temporals  stood  out  promi- 
nently, they  were  not  firm.  During  the  examination,  the  pa- 
tient had  an  attack  of  very  severe  pain,  and  clasping  his  hands 
over  the  heart  rolled  about  upon  the  bed.  He  was  flushed  in  the 
face,  and  then  broke  out  into  a  profuse  perspiration.  During 
the  attack  the  pulse  did  not  change  materially  in  character, 
but  remained  regular.  The  pain  was  described  as  very  intense, 
a  feeling  as  if  tlie  heart  was  grasped  in  something.  It  extended 
also  dov/u  the  left  arm  and  in  very  severe  paroxysms  down 
the  right  arm.  The  apex-beat  was  difficult  to  feel  on  account 
of  the  fat  mamma.  The  cardiac  dullness  was  not  increased. 
The  sounds  were  clear  at  apex  and  base;  the  aortic  second  was 
not  accentuated.  The  lungs  were  clear  on  percussion  and  the 
breath  sounds  were  normal. 

The  abdomen  was  distended  and  the  stomach  tympany  was 
high.  As  nitroglycerin  and  nitrite  of  amyl  had  no  influence 
whatever  on  his  attacks,  morphine  was  used. 

On  the  4th  he  was  better.  On  the  5tli  and  6th  he  had  very 
severe  attacks,  requiring  much  morphine.  On  the  7th  and  8th 
he  was  still  worse,  and  displayed  a  remarkable  resistance  to  the 
morphine.  Thus,  in  the  hours  between  ten  o'clock  Saturday 
night  and  1  P.  m.  on  Sunday,  he  had  received  by  mouth  and  by 
hypodermic  injection  five  grains  of  morphine,  in  spite  of  which 
he  scarcely  slept  at  all,  and  at  the  time  of  the  visit,  the  pupils, 
though  small,  were  not  extremely  contracted.  So  resistant 
had  he  appeared  to  be  to  the  morphine  that  we  discarded  the 
tablets  which  had  been  employed  and  obtained  a  fresh  solution. 


■Tiyn 


40 


ANGINA  PECTOllIS  AND  ALLIED  STATES. 


Tlic  attacks  of  pain  were  of  great  intensity  and  recurred  fro- 
qiicntly.  They  were  of  the  sharp,  agonizing  form,  and  in  the 
intervals  tliere  was  a  dull,  heavy  weight.  Only  the  fullest  doses 
of  morphine  on  Sunday  and  Monday  kept  him  free  from  pain. 
On  Tuesday  he  was  somewhat  better,  and  on  Wednesday  he  was 
almost  free. 

During  these  protracted  attacks  he  was  frequently  almost 
beside  himself  with  the  pain,  and  sweated  very  profusely,  and 
on  Sunday  and  Monday  and  Tuesday  he  had  severe  attacks  of 
vomiting.  There  was  no  fever.  On  Wednesday,  the  10th,  ho 
was  better.  I  saw  him  early  on  the  morning  of  the  11th.  lie 
had  had  a  bad  night  with  the  shortness  of  breatli.  I  found  him 
with  a  pulse  of  115,  small  in  volume;  the  heart  sounds  feeble 
and  distant.  The  change,  sc  far  as  his  hcf  rt  was  con- 
cerned, was  very  striking,  as  the  heart  sounds  had  previously 
been  quite  clear.  To-day  they  were  extremely  feeble 
and  the  action  somew.at  irregular.  Over  the  left  lung  there 
were  numerous  bronchial  rales,  particularly  in  the  axillary 
region.  In  the  evening  his  condition  seemed  really  critical. 
The  respirations  were  40,  labored;  expiration  prolonged,  and 
there  were  medium-sized  rales  heard  over  the  whole  chest.  He 
was  given  whisky  freely,  Hoffman's  anodyne,  and  ammonia, 
and  in  spite  of  the  threatening  condition  in  his  lungs  he  was 
given  during  the  night  two  or  three  hypodermic  injections  of 
morphine. 

On  the  12th  and  13th  the  cardiac  condition  was  better.  He 
had  had  no  attacks  of  pain  since  Wednesday.  The  bronchial 
symptoms  and  cough  continued. 

On  the  14th  he  was  not  nearly  so  well.  The  respirations 
were  hurried,  the  cough  troublesome,  and  over  the  whole  chest 
piping  rhonchi  were  heard.  The  pulse  was  at  about  120  and 
feeble.  He  took  his  nourishment  better,  and  the  feeling  of 
weight  about  the  heart  had  gradually  diminished.  All  along, 
the  color  of  his  face  had  kept  pretty  good,  though  that  of  the 
finger  tips  was  sometimes  a  little  cyanotic. 

On  the  15th  and  IGth  he  was  decidedly  better,  though  the 
wheezing  rhonchi  were  still  present  everywhere.  His  expectora- 
tion throughout  these  attacks  had  been  muco-purulent,  and 


m 


ANGINA  PECTORIS  VERA. 


41 


then  piinilont,  hut  the  cough  was  never  paroxysmal.  On  sev- 
eral occasions  the  urine  presented  slight  traces  of  albumin. 

January  21st.  For  the  past  few  days  the  condition  had  been 
better,  little  or  no  pain,  less  wheezing,  and  he  has  been  sleep- 
ing better  and  taking  more  food.  Last  evening,  however,  he 
had  hallucinations,  and  did  not  know  where  he  was,  thinking 
he  was  in  some  hospital,  and  that  his  wife  was  his  mother-in- 
law.  He  seemed,  however,  so  well  that  they  thought  i)artly 
that  he  was  joking.  His  wife  stated,  too,  that  on  several  occa- 
sions during  liis  illness  he  had  made  odd  remarks,  as  if  he  did 
not  realize  fully  his  surroundings.  He  spoke  of  it  himself  this 
morning  and  joked  about  it,  seeming  quite  clear  and  bright 
mentally.  The  pulse  was  soft,  90,  regular,  and  without  in- 
crease in  tension;  the  heart  sounds  were  a  little  feeble,  but 
clear.  The  bronchial  rales  were  still  to  be  heard  everywhere 
over  the  chest.  I  left  him,  saying  that  as  he  was  so  much  better 
I  probably  would  not  see  him  again. 

22d.  Dr.  Pole  sent  word  that  the  patient  died  suddenly 
at  2.45  this  afternoon.  He  wrote:  "I  saw  him  about  one 
o'clock,  after  he  had  had  a  severe  heart  pang,  which  he  de- 
scribed as  of  a  very  sharp,  cutting  character,  and  he  felt  as 
though  his  heart  had  stopped.  The  color  changed  as  usual. 
He  had  been  cold  all  day  at  the  extremities,  though  not  more 
so  than  he  had  frequently  been  before.  He  rested  fairly  well 
last  night  and  took  no  morphine,  but  throughout  the  day  he 
has  had  cutting  pains  in  his  left  hypochondriac  region." 

Case  XXXVIII.— On  the  24th  of  February,  1896,  I  saw, 
at  10.30  A.  M.,  with  Dr.  Mary  Sherwood,  Mr.  L.,  aged  fifty-nine 
years,  who  had  been  attacked  at  seven  o'clock  in  the  morning 
with  agonizing  substernal  pain. 

He  was  a  healthy  man  of  good  stock;  his  mother,  still  living, 
was  aged  nearly  ninety;  his  father  died  about  the  age  of  sixty, 
of,  so  it  is  said,  fatty  heart.  The  patient  had  been  an  abstemious 
man,  of  good  habits,  not  a  heavy  smoker.  During  the  past 
thirty  years  he  had  scarcely  had  a  day's  illness.  For  a  year  or 
more  he  had  been  using  the  bicycle,  and  had  noticed  that  he 
was  a  good  deal  distressed  and  short  of  breath  on  going  up  hill. 
For  several  weeks  he  has  had  occasional  attacks  of  pain  of  a 


42 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


singular  character  about  the  wrists,  chiolly  the  left,  which,  ho 
said,  felt  as  if  encircled  by  a  band,  lie  has  occasionally  felt 
pain  about  the  elbow  and  the  left  shoulder.  They  did  not  seem 
to  be  rheumatic.  Yesterday  he  had  a  very  comfortable  day, 
took  a  light  evening  meal,  and  went  to  bed  feeling  in  his  usual 
health.  He  was  aroused  this  morning  at  seven  o'clock  with  a 
very  severe  pain  beneath  the  breast-bone.  It  extended  to  the 
region  of  the  apex,  and  was  felt  very  severely  down  the  left 
arm  and  about  both  wrists.  He  became  pale,  but  Dr.  Sher- 
wood, who  saw  him  about  half-past  seven,  said  that  the  pulse 
was  not  much  affected.  He  obtained  temjwrary  relief  by  in- 
halations of  the  nitrite  of  amyl,  but  between  eiglit  and  nine  it 
became  so  severe  that  he  had  to  be  given  whill's  of  chloroform. 

I  saw  him  at  10.30.  He  was  a  healthy-looking  man,  with 
grayish  hair  and  mustaches;  tliere  was  no  arcus  senilis.  He 
was  not  sweating,  and  he  did  not  look  very  greatly  distressed. 
The  pulse  was  90,  of  fair  volume,  without  increase  of  tension, 
and  the  coats  of  the  vessel  were  not  specially  thickened.  The 
apex-beat  was  not  easily  to  be  felt.  The  heart  sounds  were  dull 
and  muffled  at  apex;  there  was  no  murmur  at  the  base.  The 
aortic  second  sound  was  not  accentuated.  There  was  no  dull- 
ness over  thfi  manubrium.  He  had  no  respiratory  distress,  and 
there  were  no  piping  rales.    The  al)domen  was  not  distended. 

The  intensity  of  the  pain  had  passed,  but  he  was  still  suffer- 
ing a  great  deal  from  a  very  severe  constant  pain  beneath  the 
breast-bone.  He  had  not  had  any  sweating  or  s})ecial  coldness 
of  the  hands  or  feet.  He  was  ordered  a  quarter  of  a  grain  of  mor- 
phine, and  to  have  it  repeated  at  intervals  if  necessary.  He 
improved  somewhat  through  the  day,  though  tlie  pain  did  not 
entirely  disappear.    He  had  a  pretty  comfortable  night. 

On  Tuesday,  the  25th,  he  seemed  better.  He  had  five  or  six 
free  movements  from  the  bowels,  and,  as  he  insisted  upon  walk- 
ing to  the  water-closet,  they  exhausted  him  a  good  deal. 

On  Wednesday,  the  2Gth,  without  any  active  paroxysm,  he 
had  a  great  deal  of  substernal  pain,  and  his  pulse  became  feebler. 
He  dreaded  very  much  a  return  of  the  severe  pain,  and  had 
small  doses  of  morphine  at  intervals.  I  did  not  see  him  again 
until  Thursday  at  2  p.  M.    He  had  not  had  a  good  night,  and 


ANGINA  PECTORIS  VEIIA. 


43 


had  become  much  worse  throii<,'h  tlie  morninfj,  signs  of  great 
cardiac  weaicness  having  apj)eared.  lie  had  had  no  sweating. 
When  I  saw  him  he  was  greatly  changed.  I'he  i)all()r  was 
marked,  and  tiie  general  depression  extreme.  There  was  no 
sweating;  tiie  face  was  pale,  rather  than  ashy  gray.  Thv  tongue 
was  thickly  furred.  His  mind  was  (^uite  clear,  and  he  com- 
plained only  of  feelings  of  great  exhaustion  and  an  uneasy  pain 
beneath  the  sternum.  The  head  was  low;  the  respirations  were 
not  hurried.  The  pulse  was  scarcely  to  be  counted,  only  a  few 
feeble  beats  reaching  the  wrist.  There  was  no  heaving  over 
the  pnecordia;  the  sounds  at  tiic  apex  were  only  just  audible 
in  gallop  rhythm.  At  the  base  the  gallo})  rhythm  could  just 
be  perceived.  There  seemed  to  be  a  slight  increase  in  the  area 
f  cardiac  dullness.  He  had  been  having  hypodermics  of  strych- 
ne  one  sixtieth,  but  one  thirtieth  was  ordered  every  two 
hours,  and  a  hundredth  of  a  grain  of  digitalin.  He  had  passed 
very  small  qmintities  of  urine.  At  ten  o'clock  tliat  evening  he 
was  decidedly  better;  the  pulse  was  stronger  and  the  beats  were 
regular.  There  was  still  slight  gallop  rhythm  at  the  apex.  The 
sounds  were  very  much  nu)re  distinct.  He  complained  a  good 
deal  of  an  un})leasant  gasping  in  his  breathing  at  intervals, 
which  distressed  him  very  much. 

February  28th.  Patient  had  had  a  rather  restless  night, 
sleeping  only  at  intervals,  and  being  much  distressed  by  gasp- 
ings  for  breath.  He  had  taken  small  qiuintitics  of  nourishment, 
and  had  had  no  vomiting.  The  pulse  was  regular,  snuill,  and 
about  the  same  as  last  evening.  He  had  had  digitalin  and 
strychnine  regularly  through  the  night.  He  had  a  very  com- 
fortable day,  and  seemed  altogether  better,  though  ho  had  had 
some  slight  delirium  and  wandering,  particularly  after  waking. 
He  had  slept  with  his  head  high,  and  had  not  been  quite  so 
much  troubled  with  the  cardiac  asthma.  He  had  had  no  attacks 
of  pain. 

29th.  This  morning  he  was  not  so  well.  He  had  had  a 
quarter  of  a  grain  of  morphine  at  ten  last  night,  which  quieted 
him,  but  he  was  aroused  at  intervals  with  a  distressing  sense 
of  the  need  of  air.  The  delirium  was  marked  and  he  looked 
distressed;   there  was  no  coldness  of  the  hands  and  feet,  and 


44 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


., 


no  sweating.  The  pulse  was  feeble,  irregular,  and  intermittent; 
sometimes  three  and  four  beats  were  dropped  in  succession. 
The  apex-beat  was  not  palpable.  The  heart  sounds  were  only 
just  audible  at  the  apex.  There  was  a  gallop  rhythm.  At  the 
base  the  second  sound  could  onV  just  be  heard.  There  was  no 
murmur.  Throughout  the  day  he  was  quiet,  except  for  at- 
tacks of  gasping  for  breath,  which  were  very  distressing.  At 
5.30  the  pulse  could  not  be  felt  at  the  wrist.  He  was  con- 
scious; the  respirations  were  not  hurried,  though  every  five  or 
ten  minutes  he  would  become  a  little  restless  and  gasp.  The 
heart  sounds  could  be  heard  both  at  apex  and  base;  a  very  dis- 
tinct embryo  cardia,  but  no  murmur.  The  feet  and  hands  were 
cold,  but  he  had  had  no  sweating.  It  was  rather  remarkable 
to  see  a  man  in  such  a  desperate  condition  entirely  conscious 
and  perfectly  alive  to  his  surroundings.  He  was  at  times  very 
nervous  and  restless.  Throughout  the  evening  he  grew  worse; 
the  heart  sounds  became  feebler,  and  after  a  period  of  terrible 
distress  for  an  hour  or  more,  death  occurred,  about  six  days 
after  the  onset  of  the  first  paroxysm. 


jlii 
t; 
If' 


LECTUKE  III. 

ANGINA   PECTORIS    VERA. 
PHENOMENA  OF  THE  ATTACK. 

Exciting  causes.-Symptoms.-State  of  heart  and  pulse.-Pericarditis.- 
Respiratory  features.-Gastro-intestinal  syraptoms.-Nervous  and  psy- 
chical symptoms. 

Exciting  C  vuses.— There  arc  three  important  elements- 
muscular  exertion,  mental  emotion,  and  digestive  disturbances. 
Any  muscular  effort  which  calls  for  increased  action  of  the 
heart  is  liable  to  bring  on  a  paroxysm.    Ileberden  refers  par- 
ticularly to  this:   "  They  who  are  afflicted  with  it  are  seized 
while  they  are  walking,  more  especially  if  it  be  up  hill." 
Some  patients  who  can  not  walk  except  on  the  level  without 
bringing  on  a  paroxysm  can,  however,  take  active  horseback 
exercise.    In  extreme  cases  even  an  attempt  to  move  in  bed 
or  assuming  the  sitting  posture  will  cause  an  attack,  or  such 
slight  exertion  as  stooping  to  lace  the  shoes.     Hurrying  to 
catch  a  t  ain  has  been  often  the  exciting  cause  of  a  fatal  attack 
in  the  Aibjects  of  angina.    The  muscular  and  mental  excite- 
ment jf  coitus  is  particularly  dangerous,  and  has  in  many  in- 
stances caused  death.     Two  of  my  patients  laid  great  stress 
on  the  terrible  character  of  the  attacks  which  had  followed 

the  act. 

The  well-known  effect  of  mental  emotion  has  never  been 
better  expressed  than  by  John  Hunter,  who  used  to  say  that 

«  his  life  was  in  the  hands  of  any  rascal  who  chose  to      noy 

45 


II 


)      I 


40 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


I 


and  tease  him."  And  yet  some  of  the  victims  of  angina  have 
not  found  mental  excitement  to  be  the  most  serious  exciting 
cause.  Thus,  in  Mr.  Sumner's  case,  ''  a  sudden  turn  in  his 
easy-chair,  while  quietly  reading  at  night,  would  start  up  the 
most  tearing  agony,  while  at  other  times  an  exciting  speech 
in  the  Senate,  accompanied  with  the  most  forcible  and  mus- 
cular gesticulations,  would  not  create  even  the  suggestion  of 
a  pain." — (Taber  Johnson.) 

For  some  of  the  woi"st  attacks,  however,  neither  Tmiscular 
action  nor  mental  emotion  is  responsible,  since  they  come  on 
when  the  patient  is  quiet  and  at  rest,  or  may  wake  iiim  from 
sleep.  Cold  is  another  exciting  cause,  particularly  in  the  vaso- 
motor form,  but  in  the  organic  variety  a  cold  wind,  ^ven  the 
opening  of  a  window  in  wintei*,  or  the  cold  sheets  at  night 
have  been  known  to  bring  on  an  attack. 

In  almost  every  case  in  which  the  paroxysms  recur  with 
frequency  the  patient  lays  stress  upon  the  condition  of  tlie 
stomach.  Exertion  immediately  after  ;i  full  meal,  the  eating  of 
certain  articles  of  food,  and  especially  of  late  suppers,  are  very 
apt  to  cause  attacks;  and,  as  I  will  mention  later,  there  are  in- 
stances in  which  the  dvspepsia  is  so  marked  a  feature  that  the 
character  of  the  disease  is  entirely  overlooked.  In  some  pa- 
tients flatulency  is  one  of  the  most  common  exciting  causes. 

SYMrioMS. — In  the  report  of  the  two  cases  wdiich  I  read  to 
you  at  the  end  of  the  last  lecture  I  described  the  phenomena 
associated  with  severe  attacks.  The  physician  has  not  often 
an  opportunity  of  watching  the  onset  and  coui*so  of  a  j)arox- 
ysm.  Only  once  that  I  remember  did  a  patient  have  an  attack 
in  my  consulting  room,  Mr.  S.,  to  whose  case  I  have  already 
referred  (XXVI).  As  he  sat  quietly  in  the  chair,  just  after 
the  completion  of  my  examination,  his  eyes  became  fixed  and 
he  suddenly  grasped  both  hands  over  the  heart.  For  a  moment 
the  face  did  not  change;  then  it  flushed,  and  the  neck  became 


ANGINA  PECTORIS  VERA. 


47 


swollen,  and  the  cervical  veins  full.  The  face  became  very 
much  congested,  and  tears  filled  the  eyes.  The  respirations, 
which  had  been  18,  increased  to  30  in  the  minute.  The  pulse, 
which  had  been  80,  increased  to  90,  and  became  smaller  and 
harder.  Considering  the  increase  in  the  respirations,  and  the 
congested  state  of  the  face  and  neck,  I  was  surprised  that  the 
pulse  changed  so  little.  He  remained  immobile  during  the 
entire  attack,  which  lasted  just  a  minute  and  a  half,  passing 
off  abruptly,  and  he  at  once  began  to  put  on  his  clothes. 

There  are  two  chief  elements  in  the  paroxysm:  first,  the 
pain — dolor  jpectoris  y  and  second,  the  indescribable  feeling  of 
anguish  and  sense  of  imminent  dissolution — angor  animi. 

The  resources  of  the  language  have  been  taxed  to  describe 
the  pain  of  angina  pectoris.  Patients  speak  of  a  hand  of  iron 
grasping  the  heart,  or  a  band  of  metal  encircling  it  and  being 
gradually  tightened;  or  as  though  an  enormous  weight  was 
com}  essing  the  breastbone  against  the  spine,  or  ns  though 
the  whole  chest  were  compressed  in  an  iron  case,  i  n  other  in- 
stances the  pain  is  associated  less  with  pressure  than  with  the 
sensation  of  stabbing,  as  though  a  dagger  had  transfixed  the 
heart.  While  the  maximum  intensity  of  the  pain  is  substernal 
(whence  the  name  of  sternalgia  is  derived),  it  may  be  in  the 
Tipper  or  lower  part  of  the  breastbone,  or  over  the  body  and 
apex  of  the  heart.  There  are  cases  in  which  the  chief  agony 
is  opposite  the  point  of  the  xiphoid  cartilage  in  the  scrobiculus 
cordis.  During  an  attack  there  may  be  marked  tenderness 
over  the  region  of  the  heart,  or  the  left  breast  or  the  nipple 
may  be  tender  to  the  touch.  The  pain  may  cease  as  abruptly 
as  it  began.  One  of  Parry's  patients  said  the  transitions  from 
acute  pain  to  a  state  of  ease  were  so  sudden  that  at  times  he 
felt  both  extremes  at  the  same  moment. 

A  feature  noted  by  Ileberden  and  all  the  early  writers 
was  the  radiation  of  the  pain  to  other  parts.    Ileberden  says: 


I.'  \ 


^ 


48 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


1 


i 


"  It  likewise  very  frequently  extends  from  the  breast  to  the 
middle  of  the  left  arm.  .  .  .  The  pain  sometimes  reaches  to 
the  right  arm  as  well  as  to  the  left,  and  even  down  to  the 
hands,  but  this  is  uncommon.  In  a  very  few  instances  the 
arm  has  at  the  same  time  been  numbed  and  swelled."  In 
an  instance  reported  by  Ileberden  the  patient  had  attacks  of 
pain  in  the  left  arm  without  any  affection  of  the  chest  for  fif- 
teen years  prior  to  his  sudden  death.  The  pain  most  common- 
ly extends  to  the  shoulder,  to  the  left  upper  arm,  and  to  the 
neck  of  the  same  side.  Wher  it  extends  to  the  arm  and  hand 
it  is  along  the  inner  surface  of  the  upper  arm,  and  in  the  lower 
arm  on  the  ulnar  side  in  the  distribution  of  the  ulnar  nerve. 
The  feeling  is  one  of  numbness  and  tingling,  or  of  pins  and 
needles.  There  may  be  hypera^sthesia  of  the  skin.  Very 
often  the  chief  pain  is  in  the  region  of  the  elbow,  or  there 
may  be,  as  in  a  case  I  have  already  narrated  to  you,  a  band- 
like sensation  around  the  wrist.  Sometimes  the  radiation  of 
the  pain  is  more  marked  in  the  right  arm  and  in  the  right  side 
of  the  chest.  Quain  states  that  Dr.  Morison  has  reported  a 
case  in  which  disease  of  the  right  side  of  the  heart  was  ac- 
companied by  symptoms  of  angina  affecting  the  correspond- 
ing side  of  the  chest  and  arm.  Curiously  enough,  as  noted 
by  Ileberden,  the  pain  in  the  arm  may  precede  the  angina 
attacks  for  years.  Blackall,  in  the  interesting  appendix  upon 
Angina  to  his  work  on  Dropsies^  refers  to  the  account  which 
Lord  Clarendon  gives  of  his  father's  sudden  death,  evidently 
from  angina,  "  without  one  minute's  warninge  or  feare," 
though  the  pain  is  said  to  have  been  only  in  the  arm.  As 
this  case  is  often  referred  to,  I  will  give  you  the  extract  from 
the  Life.  Mr.  Hyde  was  in  church,  and  "  found  himself  a 
little  pressed  as  he  used  to  be."  Going  to  his  home,  "  the 
pain  in  the  arm  seizing  upon  him,  he  fell  down  dead,  without 
the  least  motion  of  any  limb."    In  some  cases  there  is  sen- 


ANGINA  PECTORIS  VERA. 


49 


sory  disturbance  throughout  the  entire  left  side,  a  feeling  of 
numbness  or  tingling  in  the  neck,  arm,  and  leg.  There  are 
instances  on  record  of  extension  of  the  pain  to  the  left  testis, 
with  swelling;  or  the  attack  may  begin  with  furious  pain  in 
this  organ. 

There  are  very  interesting  areas  of  cutaneous  hyper- 
sesthesia  in  the  attacks,  chiefly  in  the  praecordia,  about  the 
pectoral  fold,  and  sometimes  along  the  side  of  the  neck.  They 
have  been  studied  particularly  by  Mackenzie,  and  are  rarely 
absent. 

I  do  not  know  of  any  clearer  view  in  explanation  of  the 
radiation  of  the  pain  in  angina  than  that  which  was  afforded  by 
the  late  Dr.  James  Ross,  of  Manchester.  I  will  quote  a  brief 
summary.  I  do  not  know  whether  it  was  ever  elaborated. 
"  When  a  viscus  was  diseased  there  was  local  pain  which  might 
be  regarded  as  of  splanchnic  origin  (praecordial  pain  in  the 
case  of  the  heart).  In  addition,  the  irritation  was  conducted 
to  the  portion  of  the  spinal  cord  from  which  the  viscus  de- 
rived its  splanchnic  nerve,  and  thence  spread  in  the  gray 
matter  of  the  posterior  horns,  whence  by  the  law  of  eccentric 
projection  it  was  referred  to  the  termination  of  the  somatic 
nerves  derived  from  the  segment  of  the  cord — the  second  and 
first  dorsal  in  the  case  of  the  heart.  This  explained  the  pain, 
shooting  between  the  shoulders  and  down  the  inner  side  of  the 
arm  (second  dorsal)  to  the  elbow  and  the  ulnar  border  of  the 
forearm  and  hand  and  ulnar  fingers  (first  dorsal)."  * 

The  subsequent  studies  of  Mackenzie  and  of  Head  have 
fully  corroborated  this  view.    Head  f  concludes  that  • 

"  1.  In  diseases  of  the  heart,  and  more  especially  in  aortic 
disease,  the  pain  is  referred  along  the  first,  second,  third,  and 
fourth  dorsal  areas. 


(■ 


*  Lancet,  1891,  i. 


f  Brain,  xvi. 


60 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


i 


"2.  In  angina  pectoris  the  pain  may  be  referred  in  addi- 
tion along  the  fifth,  sixth,  seventh,  and  even  the  eighth  and 
ninth  dorsal  ai-eas,  and  is  always  accompanied  by  pain  in  cer- 
tain cervical  areas." 

A  very  remarkable  feature  is  the  motor  disability  which 
may  follow  a  severe  attack.  The  left  arm  may  not  only  be 
numb,  but  for  a  time  almost  powerless.  Blackall  says  that  he 
has  seen  instances  in  which  the  muscles  of  the  arm  and  chest 
were  not  only  painful,  but  were  affected  with  a  twitching 
noticeable  by  the  patient,  and  visible  to  the  observer.  B.  W. 
Richardson  *  says  ^'  the  voluntary  muscles  seem  to  be  affected 
and  rigid."  Still  more  extraordinary  is  the  fact,  noted  by 
Eichhorst,  f  of  atrophy  of  the  muscles  of  the  hand  supplied 
by  the  ulnar  nerve. 

Von  Dusch,  in  his  admirable  Lelirhuch  der  Ilerzkranh- 
heiten  (which  remains  one  of  the  best  works  of  its  kind  in  the 
literature),  refers  the  hiccough,  the  occasional  difficulty  in 
swallowing,  the  globus  and  uneasy  feelings  in  the  throat,  and 
the  gastric  symptoms  to  sympathetic  involvement  of  the 
phrenic  and  vagus  nerves. 

Yaso-motor  disturbances  are  almost  constant  in  the  attack. 
A  sudden  pallor  of  the  face  may  be  the  first  indication,  and, 
as  a  rule,  vaso-constrictor  influences  prevail  in  the  severe 
paroxysms.  A  cold  sweat  breaks  out  upon  the  forehead  and 
upon  the  arms  and  legs.  In  recurring  attacks  I  have  seen  the 
skin  of  the  hands  like  that  of  a  washerwoman  from  constant 
soaking  in  perspiration.  As  in  Case  XXXV,  there  may  be 
great  pallor  and  coldness  without  sweating.  Though  rarely 
absent  in  the  organic  form  of  the  disease,  these  vaso-constrictor 
disturbances  are  often  more  pronounced  in  the  hysterical  an- 
gina.    The  countenance  is  expressive  of  the  deepest  anguish, 

*  Asclepiad,  vol.  xi. 

f  Handhuch  der  speciellen  Pathologic,  5te  Auflage. 


ANGINA  PECTORIS  VERA. 


51 


and  may  assume  a  deathlike,  aslien  hue.  In  other  instances, 
as  in  Case  XXVI,  the  face  is  suffused,  or  even  deeply  con- 
gested at  the  outset,  and  the  veins  of  the  neck  may  stand  out 
prominently.  More  commonly  in  a  fatal  paroxysm  there  is 
})allor  at  first,  which  is  followed  by  great  lividity,  as  noted  by 
Powell  *  in  a  man  who  died  in  his  consulting  room. 

Complaints  of  coldness  and  of  swelling  of  the  extremities 
are  more  frequent  in  the  hysterical  form. 

In  many  cases  of  true  angina  the  pain  alone  is  experienced, 
but  in  severe  paroxysms  the  other  factor — the  mental  element, 
the  angor  anlmi — is  also  present.  Latham  was  the  first  to  dis- 
tinguish clearly  these  two  features  of  the  attack :  "  The  sub- 
jects of  angina  pectoris  report  that  it  is  a  suffering  as  sharp 
as  an}'  that  can  be  conceived  in  the  nature  of  pain,  and  that 
it  includes,  moreover,  something  which  is  beyond  the  nature 
of  pain — a  sense  of  dying."  And  he  adds,  "  the  dying  sensa- 
tion I  have  more  fretjucntly  found  to  surpass  the  pain  than 
the  pain  the  dying  sensation."  The  one  is  in  reality  a  physi- 
cal, the  other  a  mental  phenomenon,  and  was  described  by 
Ileberden's  unknown  correspondent  as  the  sensation  of  a 
universal  pause  in  the  operations  of  I^ature,  or  a  sense  of  im- 
minent and  immediate  dissolution.  This  feature  of  the  attack 
was  certainly  referred  to  by  Seneca  (quoted  by  Gairdner) 
when  he  says,  "  As  compared  with  any  other  disease,  it  is  like 
the  difference  between  being  sick  merely  and  giving  up  the 
ghost."  Associated  with  this  sensation  there  may  be  a  feel- 
ing of  air-hunger,  or,  as  one  patient  expressed  it  to  me,  the 
same  sensation  that  one  has  after  holding  the  breath  for  as 
long  as  possible;  yet  the  attack  is  not  necessarily  associated 
with  any  special  respiratory  disturbance. 

The  attitufle  during  an  attack  is  best  described  by  the 

*  Practitioner,  vol.  xlvi,  p.  S54. 


62 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


Ni 


!     ' 


I: 


word  immobile.  If  seized  on  the  street,  the  patient  grasps  a 
lamp-post  or  leans  against  a  wall,  unable  to  stir  until  the  agony 
has  passed  oif.  The  attack  usually  comes  on  during  some 
slight  exertion,  while  the  patient  is  in  an  erect  posture.  lie 
may  be  quite  unable  to  sit  down.  In  other  cases,  when  the 
attack  comes  on  at  night,  the  patient  usually  assumes  the  sit- 
ting posture,  or  he  finds  slight  relief  by  pressing  a  firm  pillow 
to  the  chest,  or  by  pressing  firmly  against  the  back  of  a  chair. 
Immobility,  however,  is  not  a  constant  feature  of  a  parox- 
ysm of  true  angina.  In  Charles  Sumner's  case.  Dr.  Taber 
Johnson  notes  that  he  would  at  times  get  ease  by  walking  the 
floor,  quite  unconscious  of  any  increase  in  the  agony  by  the 
exertion.  In  others  the  erect  posture  is  assumed  with  the 
head  and  shoulders  thrown  back.  One  patient  assured  me 
that  in  moderate  attacks  on  the  street,  by  a  strong  effort  of 
the  will,  he  could  continue  to  walk  and  the  pain  gradually 
subsided.  This  is  like  the  gigantic  farmer,  of  whom  Forbes 
tells,  who  thought  he  could  rule  the  disease  as  he  did  his 
horses. 

State  of  the  Heart  and  Pulse. — ITeberden  states  that 
"  the  pulse  is  at  least  sometimes  not  disturbed  by  this  pain, 
consequently  the  heart  is  not  affected  by  it."  Parry  is  more 
positive  as  to  the  occurrence  of  change,  holding  that  "  what- 
ever may  be  the  state  of  the  pulse  as  to  regularity,  I  believe 
we  shall  always  find  it  become  more  or  less  feeble  according 
to  the  violence  of  the  paroxysm."  The  question  is  one  about 
which  very  diverse  opinions  are  held,  and  you  will  find  in  vol. 
i  of  the  Lancet,  1891,  several  interesting  letters  which  passed 
between  Professor  Gairdner  and  Dr.  Ilarringtoii  Sainsbury. 
It  is  quite  evident  that  there  are  good  authorities  who  accept 
the  statement  that  in  some  cases  at  least  the  paroxysm  is  not 
associated  with  special  change  in  the  pulse,  and  consequently 
not  in  the  action  of  the  heart. 


ANGINA  PECTORIS  VERA. 


53 


The  opportunities  for  observing  the  paroxysm  do  not  come 
very  often,  and  when  they  do  the  condition  of  the  patient  is 
such  that  our  efforts  are  directed  rather  toward  his  relief  than 
to  the  study  of  special  points  in  the  case.  In  an  attack  of 
moderate  severity,  such  as  Mr.  S.  (Case  XXVI)  had  in  my 
consulting  room,  the  pulse,  which  had  been  80,  increased  to 
90  in  the  minute,  and  became  smaller  and  harder.  The  ten- 
sion certainly  became  increased,  but  I  had  not  time  to  do  more 
than  count  the  radial  beats  for  half  a  minute  and  to  listen 
hurriedly  to  the  heart  sounds  before  the  attack  was  over.  In 
Case  XXXII,  in  the  first  paroxysm  in  which  I  saw  him,  Janu- 
ary 3d,  the  state  of  the  pulse  threw  me  a  little  off  my  guard; 
it  was  full  and  regular,  and  did  not  change  much,  if  at  all. 
I  am  not  certain  that  it  was  an  intense  attack,  as  he  threw  him- 
self about  on  the  bed,  the  face  was  flushed,  and  there  was  a  good 
deal  of  commotion.  Subsequently  the  pulse  became  feeble 
and  irregular,  115  a  minute.  Then,  on  the  day  before  his 
sudden  death,  the  pulse  was  soft,  regular,  without  special  ten- 
sion, and  00  a  minute.  In  Case  XXIII  the  pulse  fell  in  the 
paroxysm  to  42  in  the  minute  and  became  small  and  soft. 
For  days  the  range  had  been  about  96.  For  several  hours 
after  the  paroxysm  the  beats  at  wrist  and  at  heart  ranged 
from  40  to  50  a  minute.  Subsequently  the  heart  beats  be- 
came more  numerous  than  the  pulsations  at  the  wrist,  rang- 
ing from  GO  to  70  a  minute.  In  Case  XXXVI  I  did  not  see 
the  patient  in  his  first  paroxysm,  but  three  hours  later  the 
pulse  was  90,  of  fair  volume,  regular,  and  without  increase 
of  tension.  On  succeeding  days,  as  the  attacks  increased  in 
frequency,  the  pulse  became  small,  feeble,  and  at  times  could 
not  be  felt.  Following  a  series  of  severe  attacks,  the  pulse 
may  be  persistently  small  and  irregular,  as  in  Case  XXXV. 
In  Case  IV,  that  of  a  man,  aged  forty-five,  admitted  to  the 
University  Hospital,  Philadelphia,  February  24,  1887,  I  had 


fi 


64 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


several  opportunities  of  feeling  the  pulse  during  the  parox- 
ysm. On  the  25tli  the  pulse  was  80,  regular,  and  small,  and 
the  respirations  134.  During  an  intense  paroxysm  the  pulse 
became  more  and  more  feeble  and  at  last  could  not  he  counted. 
This  sentence  1  find  underlined  in  my  notes. 

Osgood  has  chilled  attention  *  to  a  remarkable  difference 
in  the  radial  pulse  of  the  two  sides.  The  case  was  one  of  hys- 
terical angina  in  a  young  girl,  lluchard  (p.  524)  refei*s  to  its 
occurrence  in  true  angina,  both  in  the  attacks  and  in  the  in- 
tervals. The  heart's  action  in  severe  spells  is  probably  always 
disturbed,  the  force  of  the  impulse  weakened,  and  the  rhythm 
altered.  There  are  two  changes  which  have  been  most  com- 
mon in  my  experience — namely,  the  shortening  of  the  long 
pause  and  the  occurrence  of  gallop  rhythm.  AVHiatever  may 
be  the  mechanism  of  the  production  of  these  changes,  they 
both,  I  think,  mean  the  same  thing,  weakening  of  the  ven- 
tricular systole  from  dilatation,  and  debility  of  the  muscular 
wall.  The  case  which  called  my  attention  to  the  foetal  heart 
rhythm  following  angina  I  saw  with  Dr.  Underwood,  at  Pitts- 
ton,  Pa.,  in  February,  1889.  The  patient.  Case  VI,  aged 
sixty,  had  well-marked  signs  of  myocarditis,  with  cardiac 
asthma  and  severe  pains  about  the  heart  and  down  the  ann, 
so  that  he  had  to  take  morphine  freely.  I  saw  him  shortly 
after  an  attack;  the  pulse  was  104,  weak,  and  irregular.  At 
apex  and  base  the  sounds  were  clear,  rather  ringing  in  quality, 
and  all  distinction  between  the  two  seemed  lost.  "  There  was 
a  shortening  of  the  pause  between  the  second  and  the  first 
sounds,  so  that  they  followed  each  other  in  a  unifonn  scries, 
as  in  the  foetal  heart  beat."  This,  so-called,  embryocardia  was 
a  most  persistent  featin-e  in  Case  V,  and  was  present  also  in 
Cases  XIX,  XXIX,  XXXV,  and  XXXVI.      The  gallop 


American  Journal  of  the  Medical  /Sciences,  October,  1875. 


ANGINA  PECTORIS  VERA. 


55 


rliytlim  is,  I  think,  met  with  quite  as  often,  and  was  present 
after  attacks  in  Cases  XI,  XlII,  XIX,  XXXII. 

It  does  not  fall  to  the  lot  of  many  physicians  to  witness 
a  sudden  death  in  angina,  but  there  are  observations  to  show 
that  the  pulse  beats  (and  tlie  heart)  stop  abruptly.  Potain 
mentioned  a  case  to  Iluchard  (p.  525),  and  in  the  case  of  our 
good  friend,  Mr.  E.,  Case  XXXV,  Dr.  Thayer,  who  was  pres- 
ent, tells  me  that  the  death  seemed  instantaneous — the  pulse 
ceased  at  once,  and  there  were  no  further  heart  beats. 
(Xote  C.)  As  I  before  remarked,  the  mode  of  death  resem- 
bles that  produced  by  Kronecker's  heart  puncture. 

As  the  subje(!ts  of  angina  pectoris  present  very  frequently 
the  signs  of  arterio-sclerosis  and  increased  tension,  you  will 
often  find  a  ringing,  accentuated,  aortic  second  sound.  An 
aortic  diastolic  nmrmur  is  much  more  common  than  my  fig- 
ures would  indicate.  As  I  have  already  mentioned,  mitral- 
valve  disease  is  rarely  present.  There  is  a  very  interesting 
feature  in  certain  cases  of  angina  with  recurring  attacks — 
viz.,  that  with  the  development  of  a  mitral  systolic  murmur 
the  attacks  have  ceased  as  though  a  relief  of  the  intraven- 
tricular pressure  had  been  effected  by  the  establishment  of  a 
relative  mitral  insufficiency.  My  attention  was  called  to  this 
point  by  Musser,*  who  has  had  several  illustrative  cases,  and 
Broadbent  has  dwelt  particularly  upon  this  point,  f 

Pericarditis. — During  a  severe  attack  pericarditis  may 
develop  from  the  involvement  of  the  epicardium  in  a  soften- 
ing infarct  (Kernig). :}:  Dock  *  has  described  the  onset  of 
pericarditis  in  a  case  of  thrombosis  of  the  coronary  artery, 
due  to  the  same  cause.    ITood  ||  records  a  case  in  which  the  fric- 


*  Transactions  of  the  Association  of  American  Physicians,  x,  p.  85. 
f  British  Medical  Journal,  1891,  i,  p.  747. 

If.  Quoted  in  Lancet,  August  20,  1892. 

*  Medical  and  Surgical  Reporter,  1896. 
O  Lancet,  1884,  i,  p.  205. 


66 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


tion  (lovclopcd  twenty-four  hours  after  tlie  attack,  and  aub- 
8e(iucntly  there  were  signs  of  effusion.  In  the  discussion 
which  followed,  De  11.  Hall  mentioned  a  similar  case. 

llKsriRAToitY  Featubes. — We  have  here  to  consider  sev- 
eral important  points — the  symptoms  in  the  attack,  the  rela- 
tion of  cardiac  asthma  to  angina,  and  the  interesting  group 
of  cases  of  chronic  pleuro-pulmonic  affections  in  which  angina- 
hke  attacks  of  great  intensity  occur. 

(rt)  In  the  attack,  except  slight  acceleration  in  the  move- 
ments, there  may  be  no  special  changes.  You  will  remember, 
in  reading  John  Hunter's  case,  that,  as  he  expressed  it,  he 
felt  as  though  he  had  forgotten  to  breathe;  and  a  patient  may 
feel  some  sort  of  relief  from  the  pain  by  voluntarily  fixing 
the  chest  at  the  full  inspiration,  or  by  nuiking  a  very  forced 
expiration  and  holding  the  breath.  In  a  lethal  attack  the 
respiration  may  become  slowed  and  sighing,  and  a  few  gasps 
follow  the  abrupt  cessation  of  the  heart's  action.  One  of  the 
most  remarkable  features  of  the  attack  to  which  the  attention 
was  early  called  is  the  development  of  a  bronchial  asthma. 
Erasmus  Darwin  *  called  the  disease  painful  asthma — asthma 
dolorificum — without,  so  far  as  I  can  see  from  his  account, 
any  justification.  On  auscultation  one  hears  over  the  chest 
numerous  sibilant  rules,  and  the  breathing  may  become 
labored  and  expiration  much  prolonged,  lluchard  likens  it 
to  a  condition  of  acute  emphysema.  In  Case  XXXII,  which 
I  gave  you  in  full  at  the  last  lecture,  the  attacks  of  shortness 
of  breath  with  piping  nllcs  formed  a  very  distressing  feature 
in  the  case.  The  expectoration  was  muco-purulent ;  Cursch- 
mann's  spirals  were  never  found.  Throughout  the  illness, 
which  persisted  for  several  weeks,  this  condition  continued, 
and  was  the  cause  of  much  annoyance.     Though  Ileberden 


•  Zoonomia,  third  ed.,  1801,  p.  41, 


ANGINA  PECTORIS  VERA. 


57 


(Iocs  not  refer  specially  to  the  asthma,  he  speaks  of  two  pa- 
tients who  had  spat  np  blood  and  matter.  Many  patients  have 
referred  particularly  to  the  "  wheezing  "  which  haa  accom- 
j)anied  the  attacks.  (Joodhart,*  who  describes  the  condition 
as  an  aci't;'  bronchitis,  thinks  it  of  very  grave  prognosis.  The 
same  bronchial  wheezing  is  present  in  some  cases  of  cardiac 
asthmr  ;ind  doubtless  gave  the  name  to  this  symptom. 

(h)  Cardiac  asthma  may  develop  during  an  attack  or  al- 
ternate with  the  paroxysms  of  pain.  In  another  lecture  I 
shall  speak  more  at  length  on  the  relations  of  this  feature  to 
angina,  particularly  to  the  angina  pectoris  sine  dolore.  Here 
I  wish  only  to  call  your  attention  to  the  distressing  spells  of 
dyspncTii.  chiefly  nocturnal,  which  may  come  on  in  the  sub- 
ject of  flTi'ina,  either  independently  of  or  following  an  attack. 
In  the  ciises  with  advanced  arterio-sclerosis  the  cardiac  asthma 
may  be  the  most  pronounced  and  distressing  feature,  dis- 
turbing the  patient  at  night,  making  him  dread  to  fall  asleep, 
owing  to  the  horrible  sensations  which  accompany  the  awaken- 
ing in  a  paroxysm  of  dyspnoea.  The  subject  may  die  in  an 
attack  of  angina  after  a  long  series  of  asthmatic  seizures. 

Case  XXIII,  Dr. ,  aged  forty-seven  years,  from  Santa 

Fe,  X.  M.,  had  advanced  arterio-sclerosis.  Fifteen  months 
before  his  death  he  had  an  attack  of  angina;  then  for  a  year 
he  had  many  attacks  of  cardiac  dyspnoea,  chiefly  nocturnal, 
and  once  had  transient  hemiplegia  with  aphasia.  He  died 
after  several  paroxysms  of  terrible  angina,  recurring  in  the 
course  of  twelve  hours. 

Cardiac  asthma  is  an  everyday  symptom  in  the  course  of 
chronic  valve  disease  and  cardio-sclerosis.  In  hospital  prac- 
tice it  is  as  common  as  angina  pectoris  is  rare.  It  may  recur 
in  paroxysms  very  like  angina  pectoris,  in  one  of  which  the 


*  Oxiy's  ITospital  Reports,  vol.  xliv. 


68 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


Ill 


patient  may  die.  Dresclifeld  reports  *  the  ease  of  a  woman, 
aged  forty-nine  years,  who,  when  younger,  had  been  hys- 
terical, and  later  very  neurasthenic.  Suddenly,  one  night 
she  was  seized  with  severe  dyspna?a,  without  any  cardiac  pair. 
A  week  later  she  had  a  second  attack,  again  without  pain,  and 
in  a  third  attack,  the  following  night,  £'<e  died.  There  was 
a  fibrous  myocarditis  at  apex  of  left  ventricle,  and  the  left 
coronary  artery  was  greatly  narrowed  by  an  atheromatous 
plate. 

Cheyne-Stokes  breathing  is  met  with  in  the  intervals  be- 
tween very  severe  attacks,  as  in  Cases  XXIII  and  XXXII, 
or  is  one  of  the  manifestations  of  an  advanced  arterio-sclerosis, 
as  in  Cases  V,  XI,  and  XIII. 

(c)  The  term  respiratory  form  of  angina  pectoris  has  been 
applied  to  cases  of  cardiac  asthma,  such  as  the  one  reported 
by  Dreschfeld.  I  think  the  term  more  appropriate  to  that 
interesting  group  of  cases  in  which  the  subjects  of  chronic 
pulmonary  or  pleural  disease  have  flgoniz.ing  paroxysms  of 
pain  about  the  heart,  evidently  of  the  nature  of  angina,  and 
which  may  prove  fatal. 

Let  me  mention  several  illustrative  cases: 


Case  IX. — On  February  12,  1891,  I  was  consulted  by  a 
healthy,  vigorous-looking  man,  apfcd  thirty-three  years,  who 
complained  of  shortness  of  breath  and  attacks  of  agonidng 
pain  in  the  chest. 

In  1876  he  had  pleurisy  on  the  right  side,  for  wliiLh  he  was 
tapped  repeatedly.  The  effusion  becoming  purulent,  opened 
spontaneously,  and  the  fistula  took  a  long  time  to  heal.  He 
gradually  got  stron  ;  and  well,  and  remained  so  for  nearly  ten 
years.  In  1887  he  began  to  have  attacks  of  shortness  of  breath 
at  night,  with  pain  in  the  chest.  At  first  tlv^re  was  no  short- 
ness of  breath  during  the  day  except  on  active  exertion.     In 


•  Practitioner,  vol.  xliv. 


ANGINA  PECTORIS  VERA. 


69 


the  year  1888  the  attacks  rcciirred  at  intervals.  In  1889  and 
1890  lie  was  very  much  incapacitated  by  them,  as  there  was 
great  pain  and  shortness  of  breath  on  attempting  any  extra  exer- 
tion. The  attacks  came  on  with  a  feeling  of  great  oppression 
in  the  chest  and  a  sense  of  overpowering  constriction  and  un- 
easiness in  the  region  of  the  heart.  The  pains  never  extended 
down  the  arms,  but  they  passed  up  the  neck  to  the  head.  Of 
late  they  have  recurred  at  night  with  great  regularity,  so  that 
he  dreads  to  go  to  bed.  lie  goes  to  sleep  quietly,  dreams  a 
good  deal,  but  always,  prior  to  waking  in  pain,  there  is  great 
excitement  in  the  dreams,  and  he  feels  pressure  on  the  eyeballs 
and  forehead,  which  gradually  increases  until  it  awakes  him. 
Then  he  arouses  in  terrible  agony  in  both  the  chest  and  head, 
and  the  sw'cat  pours  from  him.  The  paroxysm  lasts  from  five 
to  ten  minutes,  and  he  has  often  had  to  take  chloroform.  Dur- 
ing these  nocturnal  attacks  there  is  no  shortness  of  breath,  only 
the  agonizing  pain  in  the  region  of  the  heart  and  passing  up 
the  neck  to  the  head. 

On  examination  the  patient  snowed  an  extreme  grade  of 
contraction  of  the  right  side,  with  lateral  curvature  of  the  spine, 
flattening  in  the  mammary  and  axillary  regions,  with  scarring 
in  the  seventh,  eighth,  and  ninth  spaces,  where  the  empyema 
had  perforated.  On  percussion  there  was  flatness  everywhere 
over  this  side;  the  left  side  was  hyperresonant.  The  apex-beat 
was  not  visible;  the  heart  impulse  could  be  felt  with  moderate 
force  at  the  lower  sternum.  The  heart  sounds  were  perfectly 
clear  and  quite  natural.  The  pulse  was  regular;  the  vessels 
vvere  not  sclerosed.  There  war  no  tracheal  tugging,  and  the 
manubrium  was  clear  on  percussion.  On  rapid  exertion  the  face 
became  a  little  flushed,  but  no  murmur  developed  over  the 
heart.  The  urine  was  clear.  The  abdomen  was  distended,  the 
right  costal  border  was  curiouslj  everted  from  contraction  of 
the  c.iest,  and  the  liver  was  drawn  up  very  far,  A  short  time 
after  his  visit  to  me  the  patient  died  suddenly  in  a  paroxysm. 

The  following  case  illustrates  a  much  less  severe  form : 

A  clergyman,  aged  forty-four  years,  came  under  my  care 
April  20,  1892,  with  signs  of  local  disease  at  the  apex  of  the 


^ 


60 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


i< 


right  lung.  He  was  a  vigorous,  wiry  looking  man,  who  had 
liad  tuberculosis  for  several  }'ears;  but  the  feature  which  inca- 
pacitated him  for  work  was  the  occurrence  during  excitement, 
and  especially  when  preaching,  of  attacks  of  indescribable  dis- 
tress about  the  heart,  whicli  on  several  occasions  almost  caused 
him  to  faint.  It  was  not  a  sharp  pain,  and  there  was  no  radia- 
tion, but  ho  described  it  as  a  feeling  as  tliough  the  heart  would 
burst  or  break,  and  an  entire  impossibility  to  proceed  with  his 
sermon,  or  with  his  address.  It  was  not  accompanied  with  any 
shortness  of  breath,  and  though  the  signs  of  tuberculosis  and 
of  some  compensatory  emphysema  were  quite  marked,  yet  it  was 
this  special  sym])tom  for  which  he  sought  relief,  as  by  it  he  was 
incapacitated.  The  apex-beat  was  not  visible.  The  heart 
sounds  were  clear;  there  was  no  sign  of  hypertrophy,  and  the 
aortic  second  sound  was  not  accentuated.  The  arteries  were 
sclerotic,  and  the  pulse  tension  was  considerably  increased. 


The  condition  which  this  patient  described,  though  prob- 
ably not  true  angina,  is  of  interest  in  connection  with  this 
subject.  Public  speakers  and  others  who  have  to  address 
audiences  not  infrequently  complain  of  a  peculiar  sensation 
in  the  region  of  the  heart,  sometimes  only  an  exaggeration 
of  the  ordinary  embarrassment  which  so  many  of  ns  feel,  but 
in  other  instances  there  may  be,  with  an  increased  peripheral 
vaso-motor  contraction,  quite  evident  in  tlie  pallor  of  the  face, 
a  summation  of  cardiac  distress  which  becomes  almost  un- 
bearable. I  know  of  one  i)rofessional  friend  who  rarely  can 
get  up  to  speak  in  a  meeting  without  considerable  cardiac 
pain. 

Cases  of  chronic  pleurisy,  tuberculous  or  otherwise,  are 
very  apt  to  liave  severe  angina-like  attacks.  I  have  called 
your  attention  in  the  wards  to  ^Mary  C,  aged  twenty-four 
years,  with  chronic  bilateral  pleurisy,  wlio  came  under  our 
care  first  in  December,  ISDO,  with  an  effusion  on  the  right 
side.    She  has  had  lately  severe  attacks  of  pain  in  and  about 


ANGINA  PECTORIS  VERA. 


61 


the  heart  wliich  haAe  come  paroxysmally,  but  have  never  had 
the  intensity  of  true  angina.  I  saw  this  winter  a  woman, 
aged  thirty-six  years,  who  had  had  a  pleurisy  on  the  right 
side  of  thirteen  years'  duration,  with  chronic  disease  of  both 
apices,  and  considerable  enlargement  of  the  heart.  She  had 
had  shortness  of  breath,  and  occasional  pain  about  the  heart 
on  exertion.  She  died  in  an  attack  of  acute  dilatation  of  the 
heart,  associated  with  a  great  deal  of  substernal  pain,  much 
pallor,  and  sweating. 

Gastro-ixtestinal  Symptoms. — Nausea  not  infrequently 
accompanies  the  attack,  and  the  patient  may  vomit.  Ileber- 
den  notes  that  "  persons  who  have  persevered  in  walking  till 
the  pain  has  returned  four  or  five  times  have  then  sometimes 
vomited."  As  an  attack  ends  the  patient  may  belch  quanti- 
ties of  gas,  or  pass  flatus  from  the  bowel,  both  with  apparently 
great  relief. 

Flatulency  was  regarded  by  Butter  as  "  the  most  obvious 
and  the  most  regular  exciting  cause."  Parry,  too,  laid  great 
stress  on  the  influence  of  eructations  in  mitigating  the  pains 
produced  by  "  mal-organization  of  the  large  vessels,"  and 
quotes  ]\forgagni  to  the  effect  that  the  vulgar,  and  even  the 
physicians,  thought  the  disease  originated  in  the  flatulency. 
TiuMV  is  another  important  relation  of  the  gastro-intestinal 
features  of  angina  pectoris.  When  the  pain  is  situated  in  the 
sorubiculus  cordis,  and  associated  with  eructations  and  dys- 
pepsia, the  diagnosis  of  gastralgia  may  be  made.  There  are 
several  very  interesting  papers  on  this  question  in  the  literji- 
ture.  Leared  *  described  a  series  of  cases  of  "  <lisguised  dis- 
ease of  the  heart  "  in  which  the  "  heart  affection  was  so 
strangely  masked  by  that  of  the  stomach  that  nothing  in  the 
statements  of  the  patients  had  any  bearing  on  the  primary 

*  Medical  Times  and  Oazette,  1807,  i. 


ii 


11  ■  I 


62 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


disease."  In  several  of  his  cases  sudden  death  followed. 
Earie  *  has  written  an  elaborate  paper  on  the  cardio-pul- 
monary  features  of  gastro-hepatic  disorders.  The  attacks  of 
pain  in  some  of  his  cases  simulated  closely  angina.  Huchard 
has  a  special  section  on  what  he  called  the  j)seudo-ga8tralgic 
form  of  angina. 

In  only  two  cases  in  my  series  were  the  gastric  symptoms 
of  such  intensity  that  the  affection  was  at  first  thought  to  be 
in  the  stomach. 

In  Case  XIX  the  pains  were  at  first  altogether  in  the  upper 
part  of  the  abdomen,  and  as  they  were  of  sufficient  intensity 
to  cause  vomiting  she  was  thought  to  have  gastralgia.  It 
was  not  until  dyspnoea  came  on,  and  the  pains  became  centred 
about  the  heart  and  extended  to  the  neck  and  arm,  that  the 
diagnosis  of  angina  was  made. 

In  the  following  case  the  patient,  a  most  intelligent  man, 
insisted  that  the  entire  trouble  was  in  his  stomach. 

Case  XXVII. — ^Ir.  W.,  a  merchant  from  North  Carolina, 
was  referred  to  me  by  Dr.  Whitcliead,  October  26,  1893,  com- 
plaining of  severe  attacks  of  pain  in  the  abdomen  and  lower 
part  of  the  chest.  He  was  sixty-seven  years  of  age,  and  of  ex- 
cellent family  history.  All  his  life  he  had  had  occasional  at- 
tacks of  indigestion. 

On  the  17th  of  June,  1893,  after  helping  a  servant  to  carry 
a  hea"  y  trunk  upstairs,  he  felt  a  sensation  at  the  pit  of  the 
stomach  as  if  he  had  wrcnclied  himself  badly.  A  few  days  later, 
while  walking  up  a  hill,  the  sensation  of  pain  in  the  stomach 
returned,  and  a  week  later,  wliile  walking  fast  to  catch  a  train, 
he  had  very  severe  pain  and  shortness  of  breath.  The  taking 
of  food  apparently  made  no  difference  to  the  pain,  but  he  had  a 
good  deal  of  belching  of  wind,  and  he  insisted  upon  regarding 
the  condition  as  altogether  due  to  his  stomach.  Dr.  White- 
head, in  describing  the  case,  stated  that  the  pain  began  in  the 


Hevue  de  medecitic,  1883. 


ANGINA  PECTORIS  VERA. 


68 


epigastrium  and  passed  directly  to  the  backbone;  if  very  severe, 
it  spread  over  the  thorax;  "  asthma  comes  on;  there  is  tingling 
sensation  in  the  left  hand,  and  violent  pains  are  felt  in  the  arms. 
The  agony  is  simply  terrific."  He  never  had  any  nausea  or 
vomiting  in  the  attacks.  The  patient  was  a  very  well  preserved 
man;  the  radials  wert  firm,  tension  was  increased,  and  the 
radial  pulse  was  anastomotic.  There  was  no  excessive  cardiac 
impulse,  the  area  of  dullness  was  not  increased,  but  the  sub- 
cutaneous fat  was  very  excessive.  With  the  exception  of  a 
soft  apex  systolic  murmur,  auscultation  gave  no  indications. 
The  second  sound  over  the  aortic  region  was  of  medium  in- 
tensity. The  examination  of  he  abdominal  organs  was  nega- 
tive. There  was  no  dilatation  of  the  stomach  and  the  gastric 
juice  was  normal.  The  note  which  I  made  with  reference  to 
the  nature  of  the  case  at  the  time  was  as  follows:  "  Though  the 
possibility  has  been  entertained  that  Mr.  W.  has  gastralgia,  due 
either  to  ulcer  or  cancer,  it  seems  to  me  much  more  likely  that  he 
has  angina  pectoris."  He  was  ordered  iodide  of  potassium; 
and  throughout  the  winter  of  1893-'94  he  did  very  well,  and 
he  could  walk  a  distance  of  two  or  three  blocks  without  suffer- 
ing pain. 

On  July  2,  1894,  after  eating  a  much  heartier  dinner  than 
usual,  he  went  out  to  pay  a  visit,  and  on  leaving  the  door  of 
the  house  fell  forward  on  the  verandah  and  died  in  a  few 
moments. 

Another  by  no  means  uncommon  and  often  very  distress- 
ing symptom  is  persistent  hiccough. 

A  symptom  described  by  some  writers  has  been  the  con- 
stant desire  to  urinate — urina  spastica — and  there  may  be  a 
very  large  amount  of  urine  passed.  Griffiths  and  Massey  * 
profess  to  have  separated  a  special  leucomaine  from  the  urine 
passed  during  the  attack. 

^Nervous  and  Psychical  Symptoms. — The  mental  anguish 
has  been  described.     A  sense  of  faintness  almost  invariably 


Comptea  rendua,  Acad,  dea  sciencea,  1895, 1128. 


,1 


n 


64 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


accompanies  severe  attacks,  and  actual  loss  of  consciousness, 
syncope,  may  follow,  upon  which  feature  I  have  already 
dwelt.  There  are  interesting  psychical  manifestations  in 
angina  pectoris  upon  which  you  will  not  find  nmch  in  the 
literature.  They  are  features  of  the  myocarditis,  rather  than 
of  the  angina,  and  develop  with  the  progressive  weakness  of 
the  heart.  In  Case  V  the  patient  had  delusions  of  a  most 
painful  nature  for  nearly  six  weeks,  during  which  time  he 
liad  an  exceedingly  feeble  heart,  with  gallop  rhythm.  He  re- 
covered and  lived  for  three  years.  In  Case  VllI  the  patient 
thought  that  he  was  in  a  strange  house  and  begged  constantly 
to  be  taken  to  his  home.  You  remember  that  in  Case  XXXII 
there  were  occasional  delusions. 

Trousseau  believed  that  there  was  a  close  relationship 
between  angina  pectoris  and  epilepsy :  "  In  some  cases,  and 
perhaps  in  a  pretty  good  nund)cr  of  instances  according  to 
my  experience,  angina  pectoris  is  an  expression  of  this  cruel 
and  fearful  complaint,  and  is  a  variety  of  the  vertiginous 
form  of  the  disease — in  other  words,  it  is  an  cpileptifonn 
neuralgia.  Its  invasion  is  as  sudden,  its  progress  as  rapid, 
and  its  disappearance  as  sudden,  and,  as  T  have  already  told 
you,  it  is  not  of  very  uncommon  occurrence  to  find  persons 
who  have  in  former  years  suffered  from  angina  pectoris  be- 
come subject  afterward  to  epileptic  fits,  just  as  in  other  in- 
stances angina  pectoris  has  been  preceded  by  well-marked 
epileptiform  seizures."  *  Quite  recently  Richardson  f  has 
urged  that  angina  pectoris  is  a  special  disease,  of  a  paroxysmal 
nature,  as  distinct  as  epilepsy  and  partaking  in  many  ways 
of  its  features — a  sort  of  epileptic  countei']>art  in  the  sym- 
pathetic system.  The  two  diseases  may  co-exist.  We  have 
to  distinguish  between  the  attacks  of  nervous  palpitation  with 

*  Clinical  Medicine.    New  Sydenham  Society  edition,  vol.  i,  p.  663. 
f  Asclepiad,  vol.  xl. 


ANGINA  PECTORIS  VERA. 


C5 


cardialgia  in  opiloptics,  not  infrequent  symptoms,  and  attacks 
of  true  angina.  'J'he  only  instance  of  combination  of  the  two 
disorders  which  I  have  met  is  the  following: 

Case  111. — An  engraver,  aged  forty-eight  years,  was  ad- 
mitted under  my  care  to  the  University  Hospital,  Philadelphia. 
He  had  served  in  the  army  during  the  war  of  secession,  and  en- 
tered the  navy  as  a  marine  in  18V 1.  After  a  blow  on  the  side 
of  the  head,  in  the  latter  part  of  18T3,  he  was  insane  for  several 
months  and  required  constant  watching,  lie  recovered,  but 
has  had  ever  since,  at  intervals,  ci)ileptic  attacks,  and  he  has 
frequently  been  picked  up  unconscious  on  the  street.  For  the 
past  four  years  he  has  had  also  violent  pains  in  the  chest  with 
choking  sensation,  dilHculty  in  swallowing,  and  shooting  pains 
down  the  left  arm.  He  does  not  lose  consciousness  during  these 
attacks,  but  they  are  evidently  of  terrible  severity,  and  he  feels 
in  each  one  as  if  he  were  about  to  die.  He  has  a  well-marked 
aura  preceding  the  epileptic  fit,  which  starts  in  the  lower  part 
of  the  chest,  but  he  is  not  aware  of  any  close  association  be- 
tween the  epilepsy  and  the  attacks  of  angina.  The  patient 
was  in  a  very  bad  condition  on  admission,  almost  pulseless  at 
the  wrist,  but  after  the  administration  of  whisky  and  digitalis 
he  revived,  and  in  a  f<;w  days  seemed  quite  himself  again.  He 
had  hypertrophy  of  the  heart,  with  aortic  insufficiency. 


There  was  in  the  wards  last  June  (1895)  a  colored  man, 
aged  thirty-four  yoai*s,  who  had  remarkable  attacks  of  ])ain 
about  the  lieart  vith  unconsciousness.  He  was  a  healthy- 
looking  fellow;  the  pulse  was  not  slow,  the  tension  was  in- 
creased, and  the  radials  felt  a  little  hard.  The  heart  was  not 
enlarged;  the  aortic  second  sound  was  a  little  accentuated. 
The  urine  was  normal.  Ho  had  probably  had  syphilis.  Eight 
years  ago  he  began  to  have  pains  about  the  heart,  and  from 
July  to  September  the  attacks  wore  so  severe  that  he  was  un- 
able to  work.  In  December  they  returned,  and  ever  since, 
at  intervals,  he  has  been  subject  to  them.    Any  extra  exertion, 


66 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


w 


if 


such  as  walking  fast  up  hill,  or  mental  excitement  will  cause 
severe  pain,  xactly  under  the  left  nijiple,  often  of  great 
severity.  In  March  of  this  year,  while  working  in  a  stable, 
he  felt  a  sudden  agonizing  pain  in  the  heart,  became  giddy, 
and  fell  to  the  floor  unconscious.  He  did  not  bite  his  tongaie, 
and,  so  far  as  we  know,  he  did  not  "  work  "  the  muscles  or 
foam  at  the  mouth.  On  June  17th  he  had  a  second  attack, 
with  very  much  more  pain  about  the  heart,  which  lasted  for 
five  or  ten  minutes  before  he  became  unconscious.  On  the 
24tli  he  was  walking  on  the  street,  felt  a  severe  pain  and  great 
oppression  about  the  heart,  and  then  fell  unconscious  and  was 
brought  to  the  hospital  by  the  police  patrol.  The  loss  of  con- 
sciousness lasted  several  hours.  He  had  no  attacks  while  in 
the  ward,  and  it  seemed  impossible  to  determine  precisely  the 
nature  of  the  case — whether  the  so-called  cardiac  epilepsy,  or 
an  anomalous  type  of  angina  pectoris.  Newton  *  has  re- 
ported an  interesting  case  in  which  very  probably  both  the 
epilepsy  and  the  angina  were  associated  with  syphilis. 


*  Medical  Record,  1893,  i. 


I 


LECTURE  IV. 

ALLIED    AND   ASSOCIATED    CONDITIONS. 

I.  Syncope  anginosa.— II.  The  Adams-Stokes  syndrome.— III.  Angina  sine 

dolore.— IV.  Cardiac  asthma. 

I  WISH  to  call  your  attention  in  this  lecture  to  several  in- 
teresting conditions  closely  allied  to  true  angina  which  may 
cither  develop  in  the  course  of  an  attack  or  which  occur  spon- 
taneously in  the  subjects  of  heart  disease  or  artorio-sclerosis. 

I.  Syncope    anginosa.— Yow  remember  that  Parry  called 
angina  syncope  anginosa,  and  this  feature  of  faintness  may 
detain  us  for  a  few  moments.     The  distinguished  old  Bath 
physician,  from  whose  monograph  I  have  so  often  quoted, 
says:  "  The  angina  pectoris  is  a  mere  case  of  syncope  or  faint- 
ing, differing  from  the  common  syncope  only  in  being  pre- 
ceded by  an  unusual  degi-ce  of  pain  in  the  region  of  the  heart." 
This  is  too  strong  a  statement,  as  in  a  majority  of  the  parox- 
ysms, though  the  pallor  and  other  vaso-motor  phenomena  of 
2i  faint  may  be  present,  consciousness,  unhappily  for  the  poor 
victim,  is  not  lost.    In  looking  over  the  histories  of  my  cases 
I  do  not  ^w(\  fainting,  as  wc  usually  understand  the  term,  to 
have  been  a  common  symptom.    There  is,  of  course,  the  syn- 
cope of  a  fatal  paroxysm— aS'.  letalis,  as  Quain  tenns  it.    Dur- 
ing a  severe  attack  the  patient  may  lose  consciousness,    ^fr.  S., 
Case  XXVI,  was  once  picked  up  on  the  street.     In  Case 
XXV,  mentioned  in  connection  with  angina  and  epilepsy, 

we  could  not  determine  the  nature  of  the  attacks  of  loss 

67 


68 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


ii 


of  consciousness.  Another  feature  of  which  I  have  no  ilhis- 
trativc  example  is  thus  referred  to  by  Broadbent:  *  A  pa- 
tient who  has  ceased  to  suffer  witli  attacks  of  angina  "  may 
have  attacks  of  what  he  calls  faintness,  in  one  of  which  he 
ultimately  dies.  These  which  have  lost  the  title  to  the  name 
angina  have  an  ccpially  serious  signilicance."  And,  lastly, 
an  individual  subject  all  his  life  to  fainting  spells  may  present 
remarkable  attacks  of  the  nature  of  Gairdner's  angina  pec- 
toris sine  dolore,  about  which  I  shall  speak  shortly. 

Case  XXXIV. — T.  J.  J.,  aged  sixty-one  years,  seen  win 
Dr.  King,  ^fay  11,  1895,  complaining  of  curious  attacks  which 
occur  on  the  street  while  walking. 

The  patient  has  been  a  very  vigorous,  healthy  man,  has 
never  had  syphilis,  and  has  been  abstemious.  He  has  had  two 
attacks  of  sciatica  in  the  past  ten  years,  the  last,  a  severe  one, 
two  years  ago;  he  has  had  no  joint  airections.  lie  has  had  an 
exceptionally  healthy  life.  From  boyhood,  however,  he  has 
been  liable  to  faint  on  very  trifling  provocation,  such  as  a  vomit- 
ing attack,  a  slight  shock,  the  sight  of  blood,  or  the  extraction 
of  a  tooth.  From  any  of  these  causes  he  would  drop  instantly 
in  a  faint.  He  has  not  had  a  spell  of  this  kind  for  more  than 
two  years.  His  present  attacks  date  from  eighteen  months  ago. 
The  first  one  occurred  when  walking  from  the  Union  Station 
to  North  Avenue.  He  had  a  tingling  feeling  in  the  hands,  and 
then  a  sudden  fainting  sensation,  as  though  he  was  going  to  die. 
He  had  no  pain.  The  attack  passed  olT  in  a  few  moments.  lie 
took  the  street  car  and  then  walked  to  his  home,  having  a  sec- 
ond attack  on  the  way.  Subsequently  he  had  these  attacks  at 
intervals,  always  when  walking  on  the  street. 

On  Xovember  22,  1804,  he  had  two  very  severe  attacks,  i;nd 
he  then  consulted  Dr.  King.  In  every  instance  they  have  con.o 
on  while  he  is  walking.  He  does  not  think  that  going  up  hill 
or  walking  against  the  wind  makes  any  difference.  He  has  never 
had  an  attack  at  his  place  of  business  or  in  his  home,  and  ho 


*  British  Medical  Journal,  1891,  i,  747. 


SYNCOPE  ANGIXOSA. 


C9 


is  able  to  go  up  three  or  four  fliglifs  of  stairs  quickly  and  readily 
witlidiit  the  sliglitest  ciiibarrassinent.  They  come  on  with 
abruptness,  begin  now  every  time  with  a  fcoliiig  of  numbness 
and  tingling  in  lingers  and  hands,  wliieli  sometimes  extends  up 
the  arms,  and  wliieh  is  not  more  on  one  side  than  the  other, 
lie  iuis  never  vomited  in  an  atlacic;  tliere  is  no  cough,  and  there 
is  no  dyspna'a.  lie  turns  of  an  ashen-gray  color,  sweats  pro- 
fusely, and  feels  in  each  one  as  though  he  would  sink  away 
and  die.  It  is  this  sensation  of  impending  dissolution  which 
has  alarmed  him  so  much.  He  has  never  had  the  slightest  sen- 
sation of  pain.  During  an  attack  he  is  not  immobile,  but  he 
has  to  move  slowly.  Tiie  day  before  yesterday,  for  example,  he 
had  an  attack  before  he  reached  his  house,  and  was  able  to  get 
up  the  steps  into  the  porch  and  close  the  door;  but  he  had 
then  to  sit  down,  and  he  was  found  there  by  his  son  in  a  con- 
dition of  exhaustion  and  sweating  profusely. 

He  was  a  healthy-looking  man,  with  iron-gray  hair  and 
moustache;  no  arcus;  the  })ui)ils  were  normal.  JFe  was  not 
stout,  but  well  nourished.  The  pulse  was  72  and  regular,  the 
vessel  wall  not  specially  sclerotic,  and  the  pulse  could  be  com- 
pressed readily. 

There  was  a  slight  throbbing  in  the  vessels  of  the  neck. 
The  venules  were  marked  along  the  course  of  the  diaphragm. 
On  auscultation  there  was  a  short,  sharp,  somewhat  rough  mur- 
mur heard  only  in  the  apex  region  and  as  far  as  the  mid-axilla. 
The  apex  beat  was  not  visible,  but  was  palpable  in  the  normal 
situation,  in  the  lifth  space  just  below  the  nipple.  The  heart 
impulse  was  felt  also  below  the  ensiform  car ti  age;  there  was 
no  thrill.  The  dullness  began  on  the  fourth  costal  cartilage 
and  did  not  extend  beyond  the  nipple  line.  The  percussion  on 
the  manubrium  was  clear.  The  aortic  second  sound  was  not 
accentuated.  Both  sounds  were  clear  in  the  vessels  of  the 
neck;   the  second  was  a  little  loud  at  the  sternal  notch. 

The  lungs  were  clear.  Posture  made  no  difference  in  the 
heart  sounds  or  in  the  apex  murmur. 

The  liver  was  not  enlarged;  spleen  not  enlarged. 

After  dressing,  and  in  the  erect  posture,  the  pulse  was  88  a 
minute. 


TO 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


June  14,  1895.  I  heard  of  this  patient  to-day.  He  has 
had  no  attacks  for  a  month. 

May  5^9,  1890.  The  patient  was  seen  to-day.  lie  had  a 
severe  attack  in  April  of  this  year,  one  of  the  worst  he  has  ever 
had.  After  a  hearty  dinner  he  was  attacked  in  the  street.  Tliero 
was  no  shortness  of  hreath,  but  an  "  all-gone  "  feeling,  as  though 
he  were  going  to  expire,  but  there  was  no  pain  with  it;  sweat 
"rolled  off"  him.  He  was  well  that  evening.  He  has  had  in 
the  year  about  eight  mild  attacks.  He  had  an  attack  yesterdny. 
They  occur  nearly  always  after  meals. 

II. — The  Adams-Stokes  Syndrome. — There  is  a  most  in- 
teresting group  of  symptoms  associated  with  myocardial 
changes,  and  sometimes  with  angina,  to  which  llobert  Adams, 
of  Dublin,  first  called  attention,  and  which  Stokes  subse- 
quently described  more  fully.  Most  of  the  text-books  refer 
to  a  pseudo-apoplexy  in  connection  with  fatty  or  fibrous  myo- 
carditis, a  condition  in  which  with  a  permanently  slow  pulse 
the  patient  has  transient  vertigo,  or  falls  into  a  deep  coma, 
with  or  without  convulsive  movements.  Iluchard  lias  given 
it  the  name  maladie  d"* Adams  or  Stol'es-Adams.  As  it  is  al- 
ways pleasant  and  profitable  to  have  the  author's  first-hand 
description  of  any  symptom  or  disease,  I  will  give  you  an 
abstract  of  the  case  recorded  in  the  Dublin  Hospital  liejwrts, 
vol.  iv.  Adams,  I  may  remind  you,  was  one  of  that  distin- 
guished band  of  men,  including  Cheyne,  Colics,  R  W.  Smith, 
Graves,  Stokes,  and  Corrigan,  who  gave  sucli  renown  to  the 
Dublin  school  in  the  first  half  of  this  century.  He  is  best 
known  through  his  superb  work  on  rheumatoid  arthritis. 
Adams's  patient  was  a  man,  aged  sixty-eight  years,  who  liad 
had  in  seven  years  not  less  than  twenty  apopleptic  attacks, 
each  of  which  was  preceded  for  a  few  days  by  hebetude  and 
loss  of  memory.  The  pulse  was  permanently  slow,  and  at  the 
time  of  the  attacks  became  slower.     There  was  never  any 


ADAMS-STOKES  SYNDROME. 


71 


paralysis.  Death  followed  an  attack.  Post  mortem,  the 
heart  was  found  to  be  excessively  fatty.  There  was  no  note 
about  the  coronary  arteries.  II.  W.  Smith  *  also  noted  the 
condition  of  very  slow  pulse  with  fatty  heart,  and  Stokes  de- 
scribed ii  more  f  ully,f  and  suggested  the  name  false  or  pseudo- 
apoplexy,  lie  laid  stress  on  the  syncopal  character  of  the  at- 
tacks, their  fre<|uency,  the  absence  of  paralysis,  and  the  good 
effect  of  a  stimulant  rather  than  a  depleting  plan  of  treat- 
ment. The  first  case  which  he  gives  is  very  remarkable,  and 
is  worthy  of  a  brief  abstract,  as  recent  Anglo-American  au- 
thors have  not  dwelt  specially  upon  bis  symptom-group:  A 
man,  aged  sixty-eight  years,  was  suddenly  seized  with  a  faint- 
ing fit,  which  recurred  several  times  in  the  day.  For  the 
three  years  before  he  was  admitted  to  the  Meatli  Hospital 
he  had  never  been  free  from  the  attacks  for  any  length  of 
time,  and  had  had  at  least  fifty  such  seizures.  A  sudden  exer- 
tion or  a  distended  stomach  was  most  apt  to  cause  an  attack. 
He  had  no  convulsions,  nor  was  there  ever  anything  like  pa- 
ralysis. He  was  perfectly  insensible  for  four  or  five  minutes. 
The  pulse  was  28  per  minute,  and  the  arteries  were  "  in  a 
state  of  permanent  distention,  the  temporal  arteries  ramify- 
ing under  the  scalp,  just  as  they  are  seen  in  a  well-injected 
subject."  There  was  a  soft  hruit  with  the  first  sound.  The 
threatenings  of  attacks  he  could  recognize,  and  he  had  often 
warded  off  a  seizure  by  turning  on  his  hands  and  knees  and 
keeping  the  head  low. 

In  passing  I  may  remark  that  you  will  find  in  this  paper 
Stokes's  original  description  of  the  Cheyne-Stokcs  breathing, 
which,  though  fuller,  is  not  a  whit  better  than  Cheyne's  ac- 
count published  thirty  years  before. 


*  Dublin  Journal,  ix. 

f  Observations  on  some  Cases  of  Permanently  Slow  Pulse.     Dublin 
Quarterly  Journal,  1846,  p.  73. 


79 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


1^' 


PerinnncMt  slowness  of  tlie  heart  action  and  vertigo  or 
syncope  are  tlie  two  distinguishing  features  of  tliis  syndrome. 
Do  not  forget  that  slowness  of  heart's  action  is  tlie  special  fea- 
ture, not  simply  a  diminished  number  of  pulse  beats  at  the 
wrist.  In  myocarditis,  in  mitral-valve  disease,  and  as  an 
effect  of  digitalis  the  ra<lial  pidse  may  appear  very  slow — 35 
to  40  per  minute — while  the  heart  beats  arc  exactly  double. 
In  the  bigeminal  type  of  heart  l)cat  the  second  pulse  wave 
very  often  does  not  reach  the  wrist,  and  may  lead  a  novice 
into  the  serious  error  of  supposing  that  there  is  an  extreme 
bradycardia.  In  "  Adams's  disease "  the  pulse  rate  may 
fall  to  'JO  or  20  per  minute,  or,  in  extreme  cases,  even  to  10 
or  5. 

The  patients  are  usually  advanced  in  years,  and  show 
often  an  extreme  grade  of  arterio-sderosis,  the  arteries  feel- 
ing, as  Stokes  remarked,  both  full  and  hard. 

The  cerebral  symptoms  are  those  to  which  naturally  chief 
attention  has  been  paid.  Vertigo  is  the  most  comnioi,  and 
is  usually  transient  and  oft  repeated.  Actual  syncope  of 
three  or  four  minutes'  duration,  rcsenibil ug  closely  the  S2/7i- 
cope  a?ujhwsa,  and  doubtlo-^s  of  the  same  nature,  has  been  the 
special  feature  in  some  cases;  while  in  others  the  attack  has 
been  apoplectoid  in  its  character,  of  longer  duration,  and  has 
been  complicated  by  convulsions.  Iluchard  regards  the  slow 
pulse  as  a  result  of  changes  in  the  vagi  centres,  due  to  disease 
of  the  arteries  of  the  medulla.  He  calls  this  form  of  arterio- 
sclerosis the  eardio-Jndhar.  Transient  disturbjinces  in  the 
cerebral  circulation,  so  common  in  the  subjects  of  advanced 
arterio-sderosis,  are  responsible  for  the  syncope  and  the  apo- 
plectoid attacks,  which  remind  one  of  the  temporary  hemi- 
plegias or  monoplegias,  the  aphasias,  and  the  transient  ])ara- 
plegias,  to  which  these  patients  are  subject. 

Typical  cases  are  rot  common.     The  most  remarkable 


STOKES-ADAMS  SYNDROME. 


73 


instance  recorded  in  this  country  is  by  Prentiss,*  of  "Wash- 
ington. A  man,  aged  fifty-three  years,  witli  advanced  arterio- 
sclerosis, had  for  two  years  a  pulse  range  of  from  11  to  40  per 
minute.  During  this  time  he  was  subject  to  innumerable 
fainting  spells,  and  had  sensations  of  tightness  across  his 
chest.  Before  his  death — which  took  place  suddenly — he 
was  delirious  for  several  days.  The  heai't  was  enlarged,  but 
neither  the  aorta  nor  the  coronary  arteries  were  atheromatous. 
The  sections  of  the  medulla  showed  congestion  of  the  ves- 
sels, but  no  apparent  lesions.  Dr.  Prentiss  presented  this  re- 
markable case  at  our  meetings,  and  I  remember  very  distinct- 
ly the  advanced  sclerosis  of  the  arteries. 

The  following  case  belongs  to  this  Adams-Stokes  type, 
but  the  patient  has,  in  addition  to  the  vertigo  and  slow  pulse, 
a  sense  of  severe  oppression  in  the  chest,  suggestive  at  least 
of  an  oncoming  angina: 

J.  W.,  aged  forty-six  years,  seen  with  Dr.  Houston,  of  Troy, 
N.  Y.,  February  13,  1895.  The  family  history  is  good.  With 
the  exception  of  typhoid  fever  twenty  years  ago,  he  has  always 
been  well  and  strong.  He  has  never  had  rheumatism,  chorea,  or 
sypliilis;  he  has  never  worked  very  hard  with  his  nmsclcs.  He 
is  temperate. 

His  present  symptoms  began  about  two  years  ago  with  un- 
easy sensations  in  the  cliest  on  walking  fast.  At  first  not  at  all 
severe,  within  the  past  six  months  they  have  become  very  dis- 
tressing. He  has  not  been  able  to  lie  flat  on  his  back,  but  can 
lie  comfortauly  on  either  side  with  the  head  a  little  raised.  He 
has  no  sharp  pain  in  the  chest,  but  uneasy  sensations  and  a 
feeling  of  sufl'ocation.  He  never  has  any  cramplike  or  agoniz- 
ing feeling;  lie  has  had  at  intervals  severe  vertigo,  but  has 
never  lost  consciousness.  The  unpleasant  sensations  in  the  chest 
are  particularly  apt  to  be  present  in  the  morning.    He  has  had 


♦  Transactions  of  The  Association  of  American  Physicians,  vols,  iv,  v, 
and  vi. 

6 


74 


ANGINA  PECTORIS  AND  ALLIEI    STATES. 


1 


!i 


i| 


no  dyspepsia,  but  of  late  lias  become  very  nervous  about  him- 
self. Jle  has  to  walk  slowly,  and  on  jjoiu*,'  up  the  slifihtcst  in- 
cline he  feels  the  sense  of  oppression  in  the  chest,  lie  has  no 
cough,  no  palpitation.  About  a  year  ago  it  was  noticed  that 
his  pulse  was  very  slow,  and  in  the  early  morning  it  has  on  sev- 
eral occasions  been  counted  as  low  as  20  per  minute. 


The  patient  was  a  healthy-looking  man,  with  iron-gray  hair; 
there  was  no  arcus;  the  i)ulse  was  ;3-i  to  the  minute;  the  ten- 
sion was  i)lus,  the  upstroke  a  litlle  lal)ored,  and  the  pulse  wave 
was  well  sustained.  The  chest  was  largo;  the  cardiac  impulse 
was  not  visible;  there  were  no  areas  of  abnormal  pulsation; 
the  aorta  was  not  palpab'e  in  the  sternal  notch;  there  was  no 
increase  in  the  area  of  dullness;  no  apparent  hypertrophy; 
no  shock  at  the  base;  no  thrill. 

On  auscultation,  the  sounds  in  the  apex  region  were  clear; 
over  the  body  of  the  heart  there  was  a  rough ish,  systolic  bruit, 
heard  also  at  the  aortic  cartilage,  transmitted  feebly  to  the  ves- 
sels of  the  neck.  The  second  aortic  was  lieard,  but  was  not 
specially  accentuated;  there  was  no  accentuation  of  the  pul- 
monarv  second.  There  was  no  enlargement  of  the  liver 
or  spleen. 

I  heard  from  this  patient  in  Aj)ril,  1H0(!.  lie  has  been  a 
great  deal  better.  lie  still  has  the  brachycardia,  but  the  ver- 
tigo is  not  so  troublesome. 


III.  Angiim  Pectoris  sine  dolore. — The  thrnp  olcnionts 
in  an  attack — the  pain,  the  sense  of  anguish,  and  the  abrui)t 
ending  of  life — may  be  dissociated.  There  may  be  only  the 
severe  ])ain,  there  may  be  a  sense  of  angor  and  (»j)pression 
without  any  pain — angina  sine  dolore — or  death  may  occur 
without  a  moment's  warning. 

The  recognition  of  a  grouj)  of  cases  in  whiidi  tlic  element 
o{j)ain  is  subsidiary  was  nuidc  by  Professor  Gairdncr.  llis 
brief  description  is  as  follows: 


m 


ANGINA  PECTORIS  SINE  DOLOUE. 


to 


"  Apart  from  what  has  been  variously  termed  cardiac 
asthma,  dyspna?a,  or  orthopuoea,  wliich  in  many  cases  rece'ves 
its  clear  exi)lanation  from  the  associated  states  either  of  the 
pulmonary  circulation  or  of  the  lungs,  bronchi,  and  pleurae, 
as  disclosed  by  physical  signs,  there  is  often  an  element  of 
subjective  abnormal  sensation  present  in  cardiac  diseases 
which,  when  it  is  not  localized  through  the  coincidence  of 
pain,  is  a  specially  indefinable  and  indescribable  sensation, 
almost  always  felt  to  be  such  by  the  patient  himself.  I  make 
this  remark  deliberately,  as  the  result  of  experience,  and 
well  knowing  that  it  is  liable  to  be  brought  into  (picstion  in 
particular  instances;  that,  in  fact,  a  large  part  of  what  has 
been  described  under  the  titles  given  at  the  commencement 
of  this  paragraph  has  been  inextricably  confounded  by  sys- 
tematic writers  with  the  sensation,  or  group  of  sensations,  to 
which  I  refer.  To  this  group  of  sensations,  when  not  dis- 
tinctly acconij)anied  by  local  pain,  I  have,  in  vari(nis  instances, 
given  tlie  name  of  an(jina  sine  dolorCy  recognizing  thereby 
what  I  believe  to  be  \\-.  tnie  diagnostic  and  i)athological  sig- 
nificance, and  its  alliarxce  with  the  painful  angina  of  Ileber- 
den;  the  ])ain  in  which,  however,  as  we  have  alr'-ady  seen, 
is  an  exceedingly  variable  element,  both  in  degree  and  in 
kind."  * 

Let  me  read  you  tlie  histories  of  several  cases  of  this 
variety: 


Case  XIII. — ^fr.  IT.,  merchant,  aged  fifty  years,  who  had 
PufTcrt'd  repeatedly  from  attiuks  of  gout,  consulte<l  me  on  Octo- 
ber 'l\,  X^Wi,  coni])laining  of  op))rcss"on  and  ]>ain  in  tlic  chest, 
and  broiu  hitis.  Tliroughout  the  summer  he  had  iiad  at  times 
very  evere  ])ain  in  the  region  of  the  heart  and  down  the  left 
arm.    When  ih-st  ^oen  he  was  anaMuic,  witli  a  dilated  heart  and 


*  Reynolds's  System  of  Medicine,  art.,  Angina  Pectoris. 


w 

V 

i 

16 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


I.: 


an  enlarged  liver.  With  rest  and  iron  he  did  very  well.  I  saw 
him  at  intervals  through  the  winter;  the  attaeks  of  pain  ceased, 
but  ho  had  severe  cardiac  asthma  at  night,  which  troubled  him 
very  much.  I  subsecjueutly  saw  him  in  several  attacks  which 
followed  the  exertion  of  walking  from  tiie  street  car  to  my  house, 
in  which  the  feature  of  dyspmea  was  subsidiary,  and  that  of 
great  oppression  in  the  chest  the  most  important.  In  these  at- 
tacks the  color  changed,  )ie  became  pale,  looked  very  distressed 
and  haggard,  remained  motionless,  the  forehead  covered  with 
sweat,  the  hands  cold,  the  pulse  feeble  and  irregular.  After 
the  attack  he  exj)ressed  himself  as  having  had  a  feeling  of  in- 
definable distress  without  actual  pain.  There  was  no  dyspncea. 
The  attacks  at  night  were  sometimes  very  severe,  and  he  dreaded 
to  go  to  sleep  lest  he  sliould  be  roused  in  one.  Though  in  the 
snmmer  of  1 89'^  he  had  had  repeated  attacks  of  what  seemed  to 
be  true  angina,  yet  he  subsequently  had  only  attacks  of  the  kind 
just  described. 

In  the  spring  of  1893  he  became  much  worse;  there  were 
sigi;s  of  dilatation  of  the  heart,  with  the  gallop  rhythm,  and  a 
soft  apex  systolic  murmur,  lie  had  cardiac  dyspmea,  as  well 
as  atiacks  of  severe  oppression,  and  in  one  of  these  he  turned 
on  his  side  and  died  suddenly. 

An  attack  of  an  angina  sine  dolore  may  be  the  very  first 
indication  of  cardiac  trouble. 


An  intimate  friend,  a  man  of  about  fifty-six  years  of  age 
(Case  V),  of  excellent  iiabits  and  great  energy,  while  on  a  visit 
to  England,  walking  one  Sunday  afternoon  with  the  late  Dr. 
Hack  Tuke  up  a  slight  acclivity,  felt,  as  he  expressed  it,  a  sense 
of  intolerable  distress  about  tlie  heart,  turned  ])ale,  vomited, 
aiul  for  a  few  minutes  could  not  move  from  the  phue  at  which 
he  was  attacked.  He  recogni/ced  the  serious  character  of  the 
})aroxysm,  and  said  that  had  there  been  the  severe  pain  he 
would  have  called  it  angina.  The  attack  was  the  starting 
]H)int  of  a  series  of  very  distressing  seizures,  culminating  in  a 
protracted  condition  of  cardiac  dilatation,  which  kept  him 
in  his  bed  in  Paris  for  several  months.    On  his  return  he  was 


i:s. 


AXGINA  PECTORIS  SINE  DOLORE. 


77 


well.    I  saw 

pain  ceased, 

roubled  him 

tacks  which 

to  my  house, 

and  that  of 

In  these  at- 

ry  distressed 

L'overed  with 

uUir.     After 

eeling  of  in- 

no  dyspntra. 

d  he  dreaded 

lough  in  the 

lat  seemed  to 

s  of  the  kind 

there  were 

lythm,  and  a 

niea,  as  well 

e  he  turned 


he  very  first 


years  of  a^o 
ile  on  a  visit 

the  late  Dr. 
ed  it,  a  sense 
ale,  vomited, 
lace  at  which 
racter  of  the 
ioro  pain   he 

the  start  in;? 
linatintj  in  a 
h  k('|)t  him 
L'turn  he  was 


wonderfully  better,  took  up  his  work,  but  soon  had  anoLher 
breakdown,  bejiinnin^  with  attacks  of  luujina  sine  dohre.  In 
one  of  these  which  I  saw  the  pallor  was  extreme,  the  extremi- 
ties were  cold,  a  clammy  perspiration  bathed  the  forehead  and 
face,  the  pulse  was  extremely  feeble,  and  1  thouj^ht  any  moment 
that  he  would  die.  After  a  protracted  attack  of  cardiac  dilata- 
tion, persistently  feeble,  irreguhi!'  pulse,  without  any  dropsy, 
but  with  the  most  remarkable  psychical  manifestations,  he  re- 
covered, and  was  able  for  more  than  three  years  to  attend  to 
his  duties.  Then  he  had  a  sudden,  more  rapid  breakdown, 
with  cardiac  dilatation,  and  he  died  between  three  and  four 
years  from  the  date  of  his  first  attack.  I  have  already  shown 
you  sections  from  the  conmary  arteries  in  his  case,  which  were 
sclerotic,  and  the  myocardium  was  fibroid  in  places. 

Cask  XXX. — E.  IL,  aged  fifty-four  years,  seen  July  11, 
1895,  complaining  of  attacks  of  oppression  in  the  chest,  to 
which  he  had  been  subject  for  five  years. 

The  patient  was  a  remarkably  healthy-looking  man,  of  good 
color,  of  medium  size,  with  iron-grav  hair.  Thirty  years  ago  he 
had  syphilis,  but  was  thoroughly  treated  at  Kreuznach,  and  he 
has  had  no  troublesome  symjUoms.  lie  married  eight  or  ten 
years  ago,  and  has  healthy  children.  ITe  has  been  a  very  heavy 
smoker  froju  his  eighteenth  year;  ctherwise  temperate;  he  has 
never  done  heavy  work. 

Five  years  ago  he  noticed  that  when  making  any  extra  exer- 
tion he  had  a  sensation  in  the  chest  which  compelled  him  to 
stop.  After  resting  for  a  moment  or  two  he  could  then  go 
on.  riuM-e  was  no  ])ain  with  it.  lie  was  smoking  excessive- 
ly nt  the  time,  and  after  sto))ping  the  tobacco  the  attacks  be- 
<  u.ie  .  ;  frecpient;  but  for  two  years  they  troubled  him  a  good 
deal. 

I'hrce  years  ago  he  retired  from  business  and  speiit  a  year 
in  F  .rojie.  When  there  he  had  his  first  severe  attack.  While 
going  home  after  a  hearty  dinner  with  a  friend,  he  was  seized 
with  a  sensation  in  the  chest,  had  to  stop  in  the  street,  and  was 
taken  to  his  hotel.  The  feeling  in  the  chest  was  as  if  everything 
in  it  was  being  drawn  together  and  tightened,  but  without  any 
sharp  pain.     lie  was  very  pale,  he  perspired,  and  the  attack 


i 


i  X' 


IS 


ANGINA  PECTORIS  AND  ALLIED  STATES 


'it 

I 


II 


lasted  until  the  night.  After  the  attack  he  had  great  depression 
of  spirits. 

The  only  other  severe  attack  he  has  ever  liad  was  six  weeks 
ago.  Jle  had  been  feeling  very  well,  but  before  sitting  down 
to  dinner  an  annoying  circumstance  developed,  and  while  still 
under  the  inthience  of  the  irritation  he  sat  down  and  ate  heartily. 
Inini'diately  after  dinner  he  had  an  attack  of  terrible  opi>ression 
in  the  chest,  feeling,  as  he  expressed  it,  as  though  the  life  was 
being  squeezed  out  of  him.  The  slightest  nu)vement  would 
increase  the  oppression.  In  the  attack  absolute  quiet  is  what 
he  desires,  lie  does  not  even  wish  to  be  spoken  to,  but  feels 
that  the  mind  must  be  at  rest.  The  immobility  is  evidently  a 
very  characteristic  feature.  When  the  sense  of  constriction 
and  drawing  is  upon  him,  he  says  he  could  not  f(u-ce  himself 
to  budge  an  inch.  In  these  severe  attacks  the  pulse  becomes 
very  slow.  The  sensation  is  in  the  breast-bone  in  the  mid- 
dle. 

In  describing  his  sensations  during  a  conversation  of  at  least 
'throe  (puirters  of  an  hour  he  did  not  use  the  word  pain  once, 
and  states  exj)ressly  that  it  isn't  anything  like  i)ain,  but  an  in- 
describle  sensation  of  constriction  and  oppression.  As  he  says, 
"he  feels  as  if  the  end  of  everything  had  come"  ;  at  the  same 
time  "  he  feels  so  healthy  that  behind  it,  as  it  were,  there  is  a 
feeling  tliat  lie  still  has  a  long  time  to  live." 

In  the. two  severe  attacks  a  feeling  extended  into  the  mus- 
cles of  the  arms,  not  into  the  skin,  he  says,  but  there  was  a 
sense  of  strain  and  soreness  in  them. 

i'he  small  attacks,  as  he  calls  th^^m,  recur  with  great  fre- 
quen  -y,  and  ahuost  any  day  he  has  what  he  calls  a  hindrance; 
and  if  he  makes  any  exertion  of  more  than  usual  effort  he  has  to 
stop  sliort  and  wait  a  few  moments  until  the  sen>ation  passes  away. 
This  may  recur  two  or  three  tinu's,  and  then,  if  ^e  takes  it 
slowly,  he  can  subse(piently  walk  two  or  three  miles  witiiout 
any  distress. 

Two  other  circumstfinceH  wiiich  will  bring  on  an  attack 
are  an  unusually  full  meal  and  any  mental  worry.  He  never 
has  the  attacks  at  night. 

The  pulse  was  I'i  when  he  was  ot  rest;   after  his  running 


ANGINA  PECTORIS  SINE  DOLORE. 


79 


upstairs  and  down,  10-i;    tlie  tension  was  not  increased;    the 
Bupcrfieial  vessels  were  not  sclerosed. 

The  apex-heat  was  only  just  visihle  in  fifth  interspace  with- 
in the  nipple  line.  The  shock  of  the  first  sound  was  felt,  not 
of  the  second.  Area  of  superficial  dullness  was  reduced  by  emphy- 
sema. Both  sounds  of  the  heart  were  clear;  first  a  little  flapping 
and  valvular;  no  accentuation  of  aortic  second  sound.  The  ex- 
amination of  the  heart  was  entirely  negative.  The  liver  was  not 
enlarged. 

July  12th.  The  patient  stayed  in  town  until  I  could  see 
his  condition  in  an  attack.  He  had  had  two  to-day,  one  quite 
light  in  the  morning.  He  walked  into  the  room  somewhat 
deliberately,  talked  clearly  and  well,  and  had  not  changed  in 
color.  He  said  he  had  a  sense  of  great  distress  just  beneath 
the  breast-bone.  The  pulse  was  small  and  hard,  103  a  minute, 
with  distinctly  increased  tension.  After  sitting  down  for  a 
few  moments  his  skin  became  moist,  but  he  did  not  become 
pale.  In  the  course  of  a  few  minutes  the  attack  passed  off  with 
a  feeling  of  glow.  Afterward  there  was  a  very  decided  change 
noticeable  in  his  pulse,  which  was  softer  and  fuller,  and  of 
decidedly  low'er  tension. 

He  was  advised  to  stop  smoking,  and  ordered  a  course  of 
nitroglycerin.  I  heard  from  him  in  September  and  of  him  in 
May  (189G).  He  still  has  the  "smaller  attacks,"  as  he  calk 
them. 


The  attacks  may  alternate  with  those  in  which  agonizing 
pain  is  present,  or  they  may  entirely  supplant  the  severer 
type.  Some  of  the  milder  paroxysms,  indicating  the  begin- 
ning, as  it  were,  of  the  trouble,  appear  to  be  of  this  kind. 

An  iron-gra}',  healthy-looking  man,  aged  sixty-four  years, 
of  good  habits  and  excellent  history,  consulted  me,  May  25, 
1805,  about  curious  sensations  in  the  chest.  In  October  he 
noticed  that  when  walking  fast  there  was  a  peculiar  sensation 
about  the  heart,  as  ho  said,  "  an  aureole,  which  spread  up  his 
neck  and  head  and  went  out  to  the  hands."  If  lie  sto])pcd  for 
a  moment,  the  sensation  would  "  recede  like  a  glow  "  ;    if  he 


80 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


I 


wont  on,  it  would  eiilniinate  in  a  pain  which  wouhl  conipol 
him  to  st()|).  There  was  no  sense  of  i'aintness,  no  dyspncea,  and 
he  did  not  sweat.  Tiiey  liave  always  followed  exertion,  and 
he  lias  had  as  many  as  four  or  live  attacks  in  a  day.  His  arteries 
were  a  little  stiff,  hut  the  aortic  second  sound  was  not  accentu- 
ated. The  top  of  the  pinna  of  the  left  ear  was  calcified.  Jle 
had  never  had  gout.  1  heard  from  this  patient  on  February 
Gth  of  this  year.  The  attacks  continue,  though  less  frequent 
— only  two  or  three  a  week.  They  are  characterized  by  the  same 
spreading  glow,  beginning  at  the  heart,  and  lately  the  curious 
sensation  has  passed  down  the  right  arm  alone. 

IV.  Cardiac  Asthma. — Ilohenhui  insisted  that  in  the 
paroxysm  of  true  angina  there  was  no  ahortnesx  of  breathy 
and  yet  we  find  a  few  years  after  liis  description  tiie  tenii 
asthma  applied  to  the  condition:  Asthma  dolorijicum  (Dar- 
win), A.  arthriticmn  (Schmidt),  A.  cmivuhivitin  (Fllsner). 

In  reading  the  rejiorts  of  the  cases  published  within  tlie 
first  half  century  after  Ileberden's  pai)er,  it  is  very  evident 
that  much  confusion  existed,  and  nearly  all  forma  of  cardiac 
distress  were  termed  angina.  Desportes  emphasized  this  on 
the  title-page  of  his  monograph  (ISll)  on  angina,  which  he 
said  was  a  malady  "  prescpie  toujcmrs  confondue  avec  asth- 
ma." The  earliest  and  the  latest,  as  it  is  the  most  urgent, 
symptom  in  heart  disease  is  dj/sj>7ia'a,  which  the  older  writers 
characterized  as  asthma;  and  as  it  forms  a  common  feature 
in  eases  of  angina  pectoris  it  is  not  surprising  that  more  or 
less  confusi(m  prevailed.  Even  Stokes  docs  not  seem  to  have 
had  a  very  clear  conception  of  the  distinctions  between  these 
states,  since  he  says  that  the  disease  which  "  most  often  gets 
the  name  of  angina  pectoris  might  be  more  properly  desig- 
nated as  cardiac  asthma." 

"What,  then,  is  this  condition?  Oo  into  the  wards  and  ask 
the  patients  with  valvular  disease  of  the  heart  as  to  the  very 
£,r8t  s^nnptom  of  tlicir  trouble.     With  scarcely  an  exception 


CARDIAC  ASTHMA. 


81 


they  will  answer,  "  Shortness  of  breath."  Take  a  long  series 
of  histories  of  cases  of  arterio-selerosis;  you  meet  with  the 
same  eomi)laint  at  tlie  very  outset.  To  the  hurly,  obese  dray- 
men, to  the  lieavy  workers  and  the  hard  drinkers,  and  particu- 
larly if  in  addition  they  have  been  victims  of  the  pox,  Xemesis 
pays  her  first  visit  in  an  attack  of  shortness  of  breath — the 
first  indication  of  broken  comj)ensation  in  an  enlarged 
heart. 

Clinically,  we  meet  with  various  grades  of  intensity  in 
this  cardiac  asthma.  An  exertion,  the  ascent  of  a  pair  of 
stairs,  which  may  call  forth  only  a  fraction  of  the  reserve 
force  of  a  nonnal  heart,  may  be  too  much  for  a  right  ventricle 
(in  a  case  of  mitral  stenosis),  or  for  a  left  ventricle  (in  a  case 
of  aortic  insufficiency),  and  at  the  head  of  the  stairs  the  pa- 
tient pants,  and  is  perhaps  a  little  cyanosed.  In  chronic  val- 
vular disease  such  symptoms  may  recur  on  extra  exertion 
for  yeai-s  without  much  significance;  when  the  cardiac  dysp- 
na^a  develops  spontaneously,  loithout  extra  exertion,  the 
breakdown  is  not  far  off;  and  in  the  slow,  too  often  watery 
progress  to  the  grave  no  other  symptom  is  so  distressing  to  the 
patient.  In  cases  of  advanced  arterio-selerosis  there  are  often 
attacks  of  dyspnoea  of  great  intensity  recurring  in  paroxysms, 
often  nocturnal.  The  patient  goes  to  bed  feeling  quite  well, 
and  in  the  early  morning  houre  wakes  in  an  attack  which, 
in  its  abruptness  of  onset  and  general  features,  resembles 
asthma.  There  is  usually  a  sensation  of  proBcordial  distress, 
a  feeling  of  constriction  and  oppression,  what  the  Germans 
call  Beliemmnng.  Two  other  features  about  this  form  of 
attack  will  attract  your  attention — the  evident  effort  in  the 
breathing  and  the  presence  of  a  wheezing  in  the  bronchial 
tubes  and  of  moist  rales  at  the  bases  of  the  lungs.  The  pa- 
tient may  spring  from  the  bed  and  throw  open  the  window  in 
his  terrible  air-hunger,  and  he  assumes  an  attitude  most  favor- 


[ 


Mr 


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I  1 


82 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


able  to  tljo  working  of  all  the  accesriory  nmsflos  of  nspinition. 
Slight  fyano!*is  is  usually  [JivfCMit,  and  in  severe  panjxy.snia 
a  cold  sweat  breaks  out  iu  the  face  and  lind)s.  The  pulse 
is  feeble,  often  irregular,  and  very  suuiU,  and  on  auscultation 
one  hears  either  gallop  rhythm  or  the  f<etal  type  of  heart 
beat.  Death  may  oeeur  in  the  attack,  as  in  Dreschfeld's  case, 
the  history  of  which  I  gave  you  in  Lecture  III.  This  form 
of  cardiac  aathma  occurs  with  great  frefpiency  in  some  of  the 
subjects  of  angina  pectoris,  as  in  Cases  V  and  XII. 

And,  lastly,  the  type  of  breathing  known  as  Chcy7ie- 
Stokes  is  sometimes  a  form  of  cardiac  asthnui,  and  it  is  not 
imcommon  in  angina  pectoris.  The  curious  pause  in  his  respi- 
ration of  which  John  Hunter  spoke  was  i)robably  a  j)eriod 
of  apn<ra  in  a  paroxysm  of  Cheyne-Stokes  breathing.  It  was 
first  described  by  Cheync  in  a  cflse  of  fatty  heart,  and  you 
will  find  it  more  frecpiently  associated  with  chronic  myocar- 
ditis than  with  any  other  form  of  heart  disease. 

The  following  case  presents  features  of  (rairdner's  angina 
sine  dolore,  with  characteristic  cardiac  asthma: 

;Mr.  X.,  aged  sixty-seven,  seen  ]\Iareh  9,  ISOr),  with  Dr.  Clari- 
bcl  Cone,  complaining  of  attacks  of  terrible  oppression  in  the 
chest  and  a  sense  of  impending  death. 

The  patient  was  a  very  large-framed,  well-nourished,  vigor- 
ous-looking man.  He  had  been  always  a  very  active  business 
man,  temperate,  but  a  heavy  smoker;  he  began  in  his  eighteenth 
year,  and  has  used  as  many  as  eiglit  cigars  a  day. 

For  several  years  he  has  occasionally  been  roused  from  his 
sleep  with  a  feeling  of  op])ression  in  the  chest,  but  it  has  never 
been  very  severe.  For  the  past  two  or  three  weeks  he  has  been 
very  short  of  breath,  and  has  had  ))aroxysms  of  great  oppression 
in  the  chest,  with  dyspno-a,  feebleness  of  the  circulation,  cold, 
clammy  sweat,  and  a  sense  of  impending  dissolution.  During 
those  attacks  !lu're  is  no  actual  pain.  Mental  excitement  or 
muscular  exertion  will  bring  on  the  oppression  and  dyspnoea, 
lie  came  to-day,  however,  in  the  street  car,  and  walked  half 


CARDIAC  ASTHMA. 


83 


ft  Mock  without  nnuh  (lilliculty.  During  the  examination  he 
hud  wi'll-niarked  Chcyne-Stokes  rosi»iruti()n. 

The  pulse  was  101,  of  moderate  tens^ion,  easily  obliterated; 
the  vessel  wall  was  a  little  still'.  The  apex-ljeat  was  feeble,  just 
at  the  iiiamillijry  line;  there  was  no  shock  of  either  sound  to  be 
felt;  there  was  pdlo])  rhythm  at  the  apex,  but  no  murmur.  The 
6ee»)nd  aortic  sound  was  a  little  accentuated.  The  liver  was  not 
enlarged. 

At  J 1  r.  M.  on  the  9th  the  ])atient  had  a  very  severe  attack 
of  terrible  oppression  in  the  breath,  with  drenching  cold  sweat 
which  soaked  the  clothing.  During  the  attack  the  ])ulse  was 
10  i  and  regidar.  The  Cheyne-Stokes  breatiiing  became  ag- 
gravated during  the  attack. 

In  this  ])atient  the  attacks  were  more  than  ordinary  car- 
diac dyspncea.  ]n  addition  to  a  sensation  of  awful  oppression 
in  the  chest,  there  was  a  sense  of  impending  death,  and  the  cold, 
clammy  skin  showed  profound  involvement  of  the  vaso-motor 
system. 

For  several  weeks  this  patient  seemed  very  ill.  There  were 
two  interesting  points  in  his  treatment.  The  digitalis  seemed 
to  have  heljjed  him  very  much  when  the  pulse  tension  was  low; 
subse(|uently  he  got  a  great  deal  of  relief  from  the  full  doses  of 
nitroglycerin.  Through  the  winter  of  1895-'9G  he  remained 
pretty  well,  though  subject  to  occasional  attacks. 

I  can  not  leave  this  question  of  cardiac  dyspncea,  of  equal 
importance  pathologically  and  clinically,  without  referring 
brieily  to  certain  recent  works  upon  it.  A.  Fraenkel,  in  the 
third  edition  of  the  Real-Encyclopadie,  under  Asthma,  lias 
a  full  and  clear  stat(  ment  of  the  condition.  Rosonbach's 
IlcrzkrainklieUen  h;.s  he  most  exhaustive  discussion  on  the 
whole  subject,  full  of  suggestive  ideas,  but  not  easy  reading, 
apparently  not  even  to  his  countrymen,  as  Professor  Martins 
speaks  of  the  Lehrhuch  as  "  in  einer  etwas  dunklen  Sprache 
geschriebene."  The  essence  of  Rosenbach's  views  on  the 
relations  of  cardiac  asthma  and  angina  may  be  gathered  from 


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84 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


the  following  sentence  (page  377):  "  Dass  niir  eine  Veriinde- 
rung  in  der  Art  der  Muskelcontraction,  die  die  Stiirke  der 
Muskelleistung  durcliaus  niclit  zu  beeinflussen  brauclit,  wokl 
aber  beeinflussen  kann,  Impulse  fiir  die  sensiblen  Balineu 
liefert,  die  je  nacli  der  Erregbarkeit  derselben  und  der  Be- 
sc'haffenheit  der  betroffenen  Balinen,  die  verscliiedenen 
Formen  A'on  Sclmierz  und  Angst  auslosen,  die  wir  als  Steno- 
cardie  bezeichnen,  wiihrend  die  Yeriinderung  im  Muskel  die 
zur  Leistungsscliwiiclie  fiihren,  das  Ilauptsyniptoni  des  Asth- 
ma cardiacum,  den  wahren  Luhthunger  hervorruft."  Or,  as 
he  says  in  another  place,  "  die  wahre  Stenoeardie  ist  ein 
blosses  Zeichen  der  Regulationsstorung,  das  Asthma  cardia- 
cum ein  Zeichen  der  Compensationsstorung." 

Yon  Basch  and  his  pupils  *  have  endeavored  to  show  that 
whenever,  either  from  spasm  or  weakness  of  the  left  ventricle, 
the  blood  pressure  in  the  auricle  is  raised,  cardiac  dyspnoea 
follows  in  association  with  two  important  changes  in  the  lungs, 
viz.,  swelling  and  diminished  elasticity  =  Lungenschwelhmg 
und  Lungenstarrheit.  The  swelling,  which  may  even  be  de- 
termined by  percussion,  results  directly  from  the  overdis- 
tention  of  the  capillary  network  in  the  air  cells,  and  to  the 
same  cause  von  Basch  attributes  the  lessened  elasticity.  The 
ratio  between  the  respiratory  work  and  the  intake  of  air  is 
reduced;  and,  as  Zemer  remarks  (Studien,  Bd.  iii),  the  pe- 
culiarity of  cardiac  dyspnoea  is  in  this  respiratory  insufficiency, 
not  in  the  rapidity  and  depth  of  the  breathing.  The  "  ex- 
cursionsfiihigkeit "  of  the  lungs  is  lessened,  and  the  amount 
of  air  inspired  is  not  proportionate  to  the  w'ork  done.  Fraen- 
kel  also  refers  to  the  influence  of  the  venous  engorgement 
of  the  mucous  membrane  of  the  finer  bronchioles  as  limit- 
ing the  freedom  of  ingress  and  egress  of  the  air  to  the  alveoli. 

*  Kliniache  und  experimenklle  Studien,  i,  ii,  and  iii,  particularly  Bd. 
iii,  1896. 


* 


I 


I 
i 


CARDIAC  ASTHMA. 


85 


Wlien  we  recall  to  mind  tlie  features  of  the  attack  in 
cardiac  astlmia  and  in  certain  anginal  seizures,  the  similarity 
of  the  condition,  as  Iluchard  remarks,  to  an  acute  emphy- 
sema, the  views  of  von  Basch  appear  to  possess  at  least  a 
reasonable  probability. 


II  i 


LECTURE  V. 


PSEUDO-ANGINA   PECTORIS. 


I.  Neurotic  group :  (a)  Hysterical  and  neurasthenic  cases ;  (b)  Angina  pec- 
toriavaso-motoria;  (c)  Reflex  angina. — II.  Toxic  angina:  forms  of  heart 
pain  from  tobacco. 

An  angina  notha^  false  angina,  was  first  described,  so  far 
as  I  can  ascertain,  by  J.  Latham  in  a  paper  (1812)  on  certain 
symptoms  '*  usually,  but  not  always,  denoting  angina  pec- 
toris." According  to  Huchard,  the  term  pseudo-angina  was 
introduced  by  Lartigue  in  1846.  Walshe  called  attention 
particularly  to  this  condition,  stating  that  "  genuine  angina 
pectoris  is  undoubtedly  a  very  rare  affection.  On  the  other 
hand,  I  almost  daily  meet  with  a  form  of  complaint  combin- 
ing, in  a  minor  degree,  many  of  the  cha:  icters  of  angina ; 
and  to  this  imitation  of  the  true  disease  I  propose  to  give  the 
name  of  pseudo-angina.  I  believe  that  herein  lies  the  ex- 
planation of  Laennec's  notion  (so  discordant  with  the  experi- 
ence of  English  observers)  that  angina  pectoris  is  of  very  fre- 
quent occurrence."  The  term  which  has  come  into  general 
use,  and  is  of  no  little  value,  has  not  passed  without  criticism. 
Balfour  {The  Senile  Heart)  says:  "  The  term  *  pseudo-an- 
gina '  is  often  applied  to  anginous  pains  occurring  before 
middle  life,  especially  in  the  female  sex,  and  yet  we  see  that 
fatal  .'.ngina  may  occur  in  one  who  is  still  but  a  girl.  To  talk 
of  pseudo-angina  is,  however,  a  mark  of  ignorance  rather 

than  of  refinement  of  diagnosis;  for  angina  is  but  a  symptom, 

86 


II 


PSEUDO-ANGINA  PECTORIS. 


87 


and  if  well  marked,  it  should  no  more  be  stigmatized  as 
*  pseudo/  because  it  occurs  in  youth,  than  the  lesion  with 
which  it  is  sometimes  associated  should  be  called  functional 
because  it  happens  to  be  curable."  And  yet,  not  two  pages 
off,  he  says:  "  But  in  what  we  may  term — for  want  of  a 
better  expression — false  angina,  we  have  only  to  deal  with 
the  pain,  the  danger  of  which  depends  upon  its  cause,"  and 
in  reality  he  subsequently  acknowledges  the  wisdom  of 
Walshe's  division. 

Burney  Yeo  says:  "I  do  not  admit  a  pseudo-angina  of 
some  authors.  Hysterical  imitative  anginas,  however,  cer- 
tainly occur.  But  .  .  .  there  is  simply  a  gradation  of  se- 
verity and  curability  between  the  so-called  cases  of  pseudo- 
angina  and  those  of  true  angina." 

Morison,  too,  in  a  recent  paper,*  questions  the  correct- 
ness of  the  term:  "  A  case  of  true  angina  is  one  in  which 
there  is  no  doubt  about  the  angina,  and  there  is  no  mistake 
about  the  reality  of  the  pain  or  breast-pang  in  many  so-called 
functional  cases."  "  The  idea  of  spurious  angina  is  only  per- 
missible in  so  far  as  the  angina  is  not  associated  with  demon- 
strable lesion,"  and  tends  to  get  well.  Herein  lies  the  essence 
of  the  whole  natter — the  sjTuptoms,  on  the  one  hand,  indi- 
cate the  existenc'!  of  a  grave  organic,  usually  incurable 
malady,  and  oil  the  other,  a  condition  very  distressing,  it  is 
true,  but  rarely  serious,  and  usually  curable.  The  advantages 
in  thus  recognizing  a  functional  group  far  outweigh  any 
theoretical  objections,  and  in  a  series  of  cases  the  forms  are, 
with  few  exceptions,  fairly  well  defli.  1. 

I  have  notes  of  some  twenty  cases  of  pseudo-angina  pec- 
toris, cases  in  which  there  were  recurring  paroxysms  of  severe, 
even  agonizing  cardiac  pain,  often  ^\^th  radiation.     The  ab- 


Edinhurgh  Hospital  Reports,  toI.  iii. 


88' 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


I 


sence  of  the  mental  element — angoranimi — and  tlie  exist- 
ence of  collateral  features,  a3tiological  or  symptomatic,  served 
to  separate  them  from  the  forms  I  have  previously  consid- 
ered. I  have  only  taken  cases  in  which  the  seizures  were 
paroxysmal  and  intense;  if  one  counted  all  tlie  sligiit  car- 
diac disturbances  in  hysterical  and  neurasthenic  patients  as 
pseudo-angina,  the  list  could  be  greatly  extended. 

At  tlie  outset  let  me  emphasize  three  points  of  special 
significance : 

First.  Pseudo-angina  is  an  affection  of  women.  You  re- 
member that  in  the  series  of  organic  or  coronary  angina  there 
was  only  one  woman — a  mitral-valve  case — the  only  in.-tance 
of  true  angina  that  I  have  seen  in  a  female.  Of  the  twi  nty 
cases  of  pseudo-angina,  twelve  were  in  women.  If  we  ex- 
clude two  cases  of  tobacco  angina,  there  were  only  six  in- 
stances in  males.  In  my  series  it  was  much  more  common  in 
married  women ;  there  were  only  two  girls,  each  aged  twenty- 
two.  We  can  say  then  that  pseudo-angina  is  almost  as  much 
a  special  disorder  of  women  as  true  angina  is  of  men. 

Second,  li  occurs  in  younger  persons.  The  average  age 
of  the  subjects  of  spurious  angina  is  much  lower  than  in  the 
other  form — thirty-eight  years  in  my  series,  the  extremes 
being  twenty-two  and  sixty  years,  the  latter  a  woman  who 
had  had  attacks  for  twenty  or  more  years. 

Third.  The  patients  do  not  die.  While  fifteen  of  the 
subjects  of  true  angina  on  my  list  are  dead,  every  one  of  the 
twenty  patients  with  pseudo-angina  is  alive;  of  several  of 
the  cases  of  true  angina  I  have  lost  track. 

Two  main  groups  of  functional  angina  may  be  recognized 
— the  r  liurotic  and  the  toxic. 

I.  Xeitrotic. — The  cases  in  this  group  present  a  good 
many  minor  differences,  either  in  the  characters  of  the  attack, 
or  in  the  circumstances  which  favor  its  onset;    and,  based 


I 


i 


PSEUDO-ANGINA  PECTORIS. 


89 


•; 


upon  tliese,  various  subdivisions  have  been  made.  A  majority 
of  the  patients  are  either  hysterical  or  neurasthenic,  or  the 
features  of  the  attack  are  of  themselves  distinctive  of  hysteria. 
In  others  the  vaso-motor  phenomena  are  specially  marked, 
Avhile  in  a  third  set  of  cases  the  attacks  appear  to  be  excited 
reflexly,  either  by  peripheral  or  visceral  irritation. 

{a)  Hysterical  and  NeurastheniG  Cases. — At  the  risk  of 
wearying  you,  I  will  read  the  histories  of  a  series  of  cases, 
from  which  you  will  get  an  idea  of  the  varied  features  of  the 
attacks.  In  every  one  of  the  first  three  cases  the  existence 
of  genuine  angina  had  been  suspected,  greatly  to  the  distress 
of  the  patient  or  the  relative.  In  the  fourth  the  attacks 
were  so  anomalous  that  the  presence  of  a  tumor  in  the  medi- 
astinum was  thought  possible.  An  apprehension  lest  the  true 
nature  of  the  case  should  be  overlooked  is,  naturally  enough, 
the  feeling  uppermost  in  the  mind  of  the  attending  physi- 
cians, whom  to  convince  of  the  hopeful  nature  of  the  com- 
plaint I  have  sometimes  found  very  difficult. 


J 


Case  I. — Mrs.  X.,  aged  thirty-eight  years,  consulted  me  on 
January  9,  1894,  complaining  of  attacks  of  agonizing  pain  in 
the  chest. 

Her  father  died  at  sixty-seven  years,  of  cancer  of  the  stom- 
ach; her  mother,  of  nephritis,  at  the  same  age.  There  are  no 
nervous  aftections  in  the  family. 

At  the  age  of  six  she  had  rheumatic  fever,  and  at  twenty- 
one  rheumatic  sciatica,  which  has  returned  once  or  twice,  but 
not  within  the  past  ten  years.  She  has  been  married  sixteen 
years  and  has  two  children.  Until  about  six  years  ago  she  was 
subject  at  times  to  fainting  fits,  which  would  come  on  without 
any  definite  cause.  She  had  them  almost  from  her  childhood, 
and  I  can  not  get  either  from  herself  or  from  her  husband  any  ac- 
curate information  as  to  her  behavior  in  these  attacks,  which 
are  apparently  quite  transient,  and  not  associated  with  con- 
vulsive movement,  nor  does  she  apparently  always  lose  con- 
7 


I 


1 

i 

■ 

; 

1 

\ 

» 

. 

90 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


i      1 


seioiisncss.  She  is  a  woman  of  a  fjood  deal  of  character  and  de- 
termination, and  of  executive  skill,  and  docs  not  give  one  the 
impression  of  being  of  a  neurotic  luibit.  Slie  luis  always  been 
able  to  do  a  great  deal  of  walking  and  has  not  suH'ered  specially 
with  shortness  of  breath.  Five  years  ago  she  had  an  attack  of 
appendicitis,  from  which  she  recovered  without  oi)eration.  In 
the  spring  of  1893,  when  returning  from  Colorado,  and  after 
a  good  deal  of  mental  worry,  she  had  an  attack  of  very  severe 
pain  in  the  chest.  It  came  on  after  exertion  and  exposure  to 
the  wind  in  walking.  The  pain  was  of  terrible  severity,  ex- 
tended up  the  neck  and  down  the  arms;  but  she  was  able  to 
move  about  in  it  and  was  a  good  deal  excited.  Since  that  at- 
tack she  has  been,  at  intervals,  a  little  short  of  breath  on  exer- 
tion. She  has  had  two  of  the  severe  attacks  since;  one  last  sum- 
mer at  the  seaside,  when  walking  on  the  sand,  the  other  two 
months  ago.  Both  of  these  were  of  great  severity;  the  pain 
was  agonizing;  she  became  gray  and  cold  and  exhausted,  and 
the  skin  was  covered  with  a  clammy  perspiration.  She  states, 
too,  that  she  had  a  sensation  as  though  she  could  not  live 
through  it.  One  of  these  attacks  was  followed  by  a  transient 
facial  paralysis.  Last  August,  for  the  first  time  in  her  life,  she 
began  to  have  headaches,  which  have  recurred  as  often  as  two 
or  three  times  a  week.  They  arc  of  the  type  of  migraine,  and 
come  on  with  disturbance  of  vision;  she  sometimes  sees  figures 
and  queer  things;  once  she  had  hemianopia.  The  attacks  pros- 
+T-;:te  her  very  much. 

About  the  middle  of  December  her  feet  and  ankles  began  to 
swell,  particularly  at  night.  At  first  there  was  little  or  no 
pitting,  but  now  they  are  sometimes  swollen  to  the  knees.  The 
urine  has  been  normal  in  quantity  and  without  albumin  or  tube 
casts. 

The  patient  was  a  well-nourished,  healthy-looking  woman; 
pulse  80,  regular,  without  increase  in  tension,  and  the  vessel 
was  not  sclerosed.  The  thyroid  gland  was  not  enlarged,  and 
there  was  no  puffiness  of  the  face  or  above  the  clavicles.  The 
feet  and  ankles  at  the  time  of  examination  were  not  ocdematous. 
The  examination  of  the  heart  and  other  organs  ,vas  entirely 
negative. 


i 


i 


' 


^? 


PSEUDO-ANGIXA  PECTORIS. 


91 


( 


A  hopeful  prognosis  was  given  in  the  case,  hased  on  the 
view  tlmt  the  attacks,  though  severe,  were  probahly  pseudo- 
angina.  Tlie  ocourreuce  of  migraine,  with  which  pseudo- 
anginal  attacks  may  alternate,  and  the  swelling  of  the  feet 
without  evidence  of  heart  or  renal  disease,  were  corroborative 
features.  I  have  heard  of  this  case  several  times;  she  got 
better,  and  the  painful  heart  attacks,  when  I  last  saw  her 
husband,  six  months  ago,  had  not  recurred. 

Case  II. — Mrs.  F.  R.,  aged  forty-two  years,  seen  April  9, 
1894,  complaining  of  attacks  of  agonizing  pain  in  the  chest. 

The  i)aticnt  comes  of  a  very  nervous  family,  and  one  sister 
is  in  a  lunatic  asylum. 

She  was  well  and  strong  until  two  years  ago;  she  has  had 
five  children,  the  youngest  six  years  old.  She  has  never  had 
any  special  illnesses.  She  was  not  specially  nervous  as  a  young 
girl,  and  had  no  crying  spells  or  hysterical  attacks.  Her  domes- 
tie  relations  are  congenial  and  satisfactory. 

Tlie  present  trouble  began  two  years  ago  last  February,  when 
one  morning  she  had  an  attack  of  severe  pain  in  the  chest.  It 
began  in  the  pit  of  the  stomach,  became  most  intense  under  the 
loft  breast,  and  extended  round  the  shoulder.  As  she  expressed 
it,  she  thought  death  had  come.  She  got  cold,  broke  oiit  into 
a  profuse  perspiration,  and  during  the  attack  was  completely 
helpless.  The  attack  lasted  for  about  an  hour  and  left  her  much 
prostrated.  During  the  succeeding  year  she  had  about  four  at- 
tacks, each  of  great  severity  and  identical  in  character.  In  the 
past  year  they  have  become  more  frequent;  thus,  she  has  had 
two  in  the  past  month.  The  last  attack  was  on  the  1st  of  xVpril. 
She  folt  comfortable  in  the  morning  when  she  got  up,  but  after 
breakfast  felt  a  little  drowsy  and  heavy,  and  lay  down  on  the 
sofa.  The  attack  came  with  the  greatest  rapidity  and  was  so 
severe  that  she  could  not  rise.  The  breath  gets  short;  she  feels 
a  sensation  of  deathly  coldness  about  the  heart,  and  the  chief 
pain  is  under  the  left  breast.  She  can  not  move  about,  and  when 
the  pain  is  at  its  height  she  can  not  bear  to  be  touched.  As 
it  comes  on  she  loosens  her  clothing,  but  as  the  attack  increases 


1 


Jrt 


92 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


I  ■ 


It  i 


in  severity  she  is  <iuite  beside  herself,  tovsses  about,  and  is,  as 
she  says,  ahiiost  dead.  She  j,n'(»aiis  a  great  deal,  and  in  some 
of  them  has  eried  out  very  loudly,  ller  iiusband,  who  is  a 
traveller,  has  only  seen  her  in  two  attaeks,  both  of  whieh  eanie  on 
with  great  suddenness.  She  got  very  eold,  the  faee  beeame 
l)inehed  and  drawn,  at  first  a  little  eongested,  and  then  pale. 
Twiee  she  vomited  in  the  attaek.  The  duration  has  been  from 
a  quarter  of  an  hour  to  an  lu)ur.  She  has  had  to  have  mori)hine 
hypodermieally  on  several  oeeasions.  After  they  pass  away  she 
feels  miserable  and  is  wretehed  for  two  or  three  days.  Some- 
times the  whole  body  is  sore  after  an  attaek. 

She  knew  of  no  speeial  eireumstanee  apt  to  induee  an  at- 
tack. She  was  low-si)irited  at  times  and  notieed  that  she  has 
been  a  little  despondent  prior  to  their  onset.  She  has  not  been 
short  of  breath  on  going  upstairs  or  uphill;  not  more  than 
might  be  exjjeeted  in  a  stout  wonuin.  Exertion  has  never 
brought  on  the  attaek. 

The  ])atient  was  a  large,  stout,  healthy-looking  woman. 
There  was  no  arcus;  the  color  was  good;  the  tongue  clean; 
the  temporal  arteries  not  sclerosed;  pulse  84,  readily  com- 
pressed; the  vessel  wall  was  not  sclerosed.  There  was  slight 
throbbing  in  the  vessels  of  the  neck.  Percussion  was  clear  on 
manubrium.  The  cardiac  dullness  began  on  the  fourth  rib. 
At  first  right  interspace  there  was  a  soft  systolic  murmur,  and 
the  aortic  second  sound  was  here  a  little  accentuated.  The  first 
sound  was  loud  and  dear  upon  sternum;  there  was  no  murmur 
at  the  apex.  There  was  no  pain  on  firm  pressure  over  manu- 
brium or  adjacent  parts. 


The  soft  bruit  at  the  aortic  area,  and  the  accentuation 
of  the  second  sound,  made  me  a  little  suspicious  of  this  ease, 
though  the  general  features  of  the  attack  wore  rather  those 
of  pseudo-angina.  The  subsequent  history,  as  obtained  from 
Dr.  G.  W.  Xorris  and  from  her  husband,  on  October  27,  1894, 
and  July  7,  1895,  shows  that  she  steadily  improved  and  the 
attacks  have  now  ceased. 


1 


PSEUDO-ANGINA  PECTORIS. 


98 


Case  111. — !^^rs.  ]i.,  ngod  tliirly-three  years,  seen  with  Dr. 
Smith,  of  Jlavre-de-dnu'c,  J-Y-hruary  11,  IS!)."),  comph'ining  of 
attacks  of  ])ain  about  the  heart  ajiJ  sliortness  of  breath. 

Her  mother  died  of  apojik^xy  at  sixty;  her  fatlier  hud  a 
lien)ii)k'«,'ie  attack  two  years  ago. 

The  patient  was  healthy  as  a  chikl.  At  her  seventeenth 
year  had  nervous  j)rostration  with  heachiches.  She  has  never 
had  any  fevers,  and  has  not  had  chorea  or  rhe'imatism.  She 
has  been  married  for  twelve  years;  lias  had  three  children;  the 
youngest  is  between  three  and  four  years  of  age. 

The  symptoms  of  which  she  now  complains  began  about 
two  years  and  a  half  ago.  During  lier  last  pregnancy  she  had 
acute  nei)hritis,  but  after  delivery  the  droi)sy  disappeared  rapid- 
ly. Within  about  six  months  she  began  to  have  attacks  of  pal- 
pitation and  })ains  about  the  heart.  These  are  very  apt  to  come 
on  five  or  six  days  before  the  menstrual  period.  She  has  two 
grades  of  attacks:  In  the  severer  type  she  gets  very  cold  in  the 
hands  and  feet.  The  heart  begins  to  throb;  she  has  choking 
sensations  in  the  neck,  and  a  sense  of  pain  and  oppression  in 
the  region  of  the  heart.  The  pains  do  not  extend  to  the  arms. 
The  face  gets  flushed,  sometimes  very  much  congested.  She 
becomes  very  nervous,  and  the  pain  is  so  intense  that  she  re- 
quires morphine.  The  attacks  come  on  at  any  time,  but  exer- 
cise, heavy  work  of  any  sort,  and  worry,  have  seemed  the  most 
common  exciting  causes.  In  the  milder  attacks  she  has  a  little 
shortness  of  breath,  the  face  becomes  flushed,  and  there  is  a 
sense  of  oppression  about  the  heart.  They  often  pass  off  if  she 
takes  a  hot  drink  or  a  dose  of  Hoffman's  anodyne;  she  has 
never  fainted.  She  has  no  dyspepsia,  nor  does  she  think  that 
anything  she  eats  ever  brings  on  an  attack.  She  has  been  ex- 
ceedingly nervous  and  worried  about  her  condition,  particular- 
ly since  a  physician  told  her  a  year  ago  that  she  was  liable  to 
die  suddenly.  Up  to  a  year  ago  she  weighed  only  a  hundred 
and  fifteen  pounds;  she  has  rapidly  increased  in  weight  to  a 
hundred  and  forty-three  pounds.  She  was  a  healthy-looking 
woman  of  a  florid  complexion.  She  did  not  look  of  a  nervous 
temperament.  The  pulse  was  good,  100  a  minute,  without  in- 
creased tension;    the  arteries  were  not  sclerotic.     The  condi- 


I 


'!,>-T 

m 


94 


ANGINA  PECTOiaS  AND  ALLIED  STATES. 


tion  of  the  heart  wns  negative,  the  aortic  second  sound  was  rinp;- 
in<,'  and  accentuated.  The  i)Ui)ils  were  equal;  she  had  no  arcus 
ticuilis. 

There  seemed  very  little  doubt  that  this  wna  a  pseudo- 
angina,  and  I  reassured  her  upon  the  (piestion  of  sudden 
death.  I  heard  of  this  patient  on  July  l.'5th  and  on  Decem- 
ber 30th.  She  has  not  had  a  severe  attack  since  February; 
for  a  few  months  she  had  ''  threatcnings,"  as  she  calls  them; 
since  July  she  has  been  quite  well. 

The  followinj;;  case  is  of  interest  from  the  intensity  of  the 
paroxysms  and  the  hypenesthesia  of  the  left  arm.  She  had 
been  alarmed,  too,  by  the  serious  view  which  had  been  taken 
of  her  condition : 

Case  IV. — ^^fiss  C,  aged  twenty-two  years,  referred  to  mo 
September  29,  181)1,  by  J)r.  Clark,  of  Skancat<'les,  conii)lain- 
ing  of  remarkahlo  attacks  in  the  re<,non  of  the  heart. 

The  family  history  is  good,  and  she  has  herself  always  en- 
joyed very  good  licalth.  She  is  evidently  a  high-strung,  nervous 
girl,  who  has  studied  hard.  When  quite  young,  about  the 
twelfth  year,  she  had  for  a  time  pain  in  the  left  side  about  the 
heart  and  sensations  of  coldness. 

The  present  complaint  has  persisted  for  between  two  and 
three  years.  She  describes  a  pain,  more  or  less  constant  in  the 
left  front  of  the  chest,  which  sometimes  goes  down  the  arm, 
which  becomes  numb.  She  says  she  is  never  without  this  pain, 
and  that  it  sometimes  keeps  her  from  sleeping.  Then  she  had 
sudden  spells,  in  which  she  has  a  terrible  sensation  of  spasm 
in  the  region  of  the  heart,  as  though  something  had  grasped  her. 
It  differs  altogether  from  the  other  pain.  In  severe  attacks  it 
has  lasted  all  night,  and  she  has  had  to  gasp  for  breath.  She 
does  not  perspire.  The  left  arm  becomes  nimib,  often  tingles, 
and  in  severe  attacks  the  numbness  extends  to  the  left  leg.  The 
left  arm  feels  almost  paralyzed  and  is  tender,  and  she  can  not 
use  it  in  the  attacks.  There  may  be  headaches,  but  she  is  never 
sick  at  the  stomach.      She  never  has  any  special  coldness  of 


rSEUDO-ANGlXA  PECTORIS. 


05 


•(•US 


-'111 ; 


the  oxtroinitioH.  Slio  lias  only  had  four  -if  these  very  sovore 
paroxysms  witliiu  the  year.  Durin;;  tlieni  she  takes  elilorol'oriii 
and  nitrite  of  ainyl.  Tiiey  have  never  l)een  broui^'ht  on  l)y  exer- 
tion, and  she  has  been  able  to  play  tennis  (piito  aetively.  Kx- 
fitenient  and  emotion  most  fre(|ueiitly  cause  them. 

The  jtatient  was  evick'nlly  very  neurotic.  She  had  no  heart 
disease,  no  increased  tension,  and  no  sclerosis  of  the  vessels. 
An  interestini,^  feature  was  the  ^'reat  sensitiveness  of  the  left 
hand  and  arm.  She  junii)ed  at  once  when  1  touched  the  wrist 
in  order  to  feel  the  pulse.  The  various  forms  of  sensation  in 
it  were  p'  rf'-ctly  normal.  Thoufih  sensitive  to  the  touch,  she 
feels  it  nunil)  and  heavy.  The  sensitiveness  did  not  extend  to 
the  skin  o"  the  chest. 


The  condition  lind  hccn  tlio  cniiso  of  a  good  deal  of  nlann 
to  her  friends,  and  a  diagnosis  had  been  made  by  one  of  lior 
])liysicians  of  a  tumor  pressing  in  the  region  of  tlie  lieart. 
She  was  given  a  very  favorable  prognosis. 

I  saw  tliis  patient  for  a  few  moments  abont  a  year  ago. 
She  had  entirely  recovered  from  her  attacks  and,  thongh 
nervons,  seemed  very  well. 

Hysterical  angina  in  the  male  is  usually  a  very  well- 
characterized  affection.  The  following  cases  arc  the  most 
typical  which  I  have  seen: 


tn 


^^ 


Case  Y. — "W.  IT.,  seen  with  Dr.  Purvis,  of  Alexandria,  aged 
thirty-two  years,  complaining  of  severe  attacks  of  pain  about  the 
heart. 

The  patient  comes  of  excellent  German  stock.  His  mother 
is  alive  and  his  brothers  and  sisters  are  well  and  strong;  there 
are  no  special  nervous  troubles  in  the  family.  Though  an  liotel- 
kcejier  he  has  been  very  abstemious  in  the  use  of  alcohol.  He 
has  never  had  syphilis.  He  has  been  nervous  from  boyhood. 
When  about  fifteen  he  had  a  fright,  after  Avhich  he  had  nervous 
spells,  called  fits,  for  several  years.  From  his  description,  they 
were  evidently  severe  hysterical  attacks.  At  the  age  of  twenty- 
three  he  had  scarlet  fever  and  diphtheria,  and  nearly  lost  his 


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96 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


life.  For  the  past  six  years  he  has  had  a  great  deal  of  mental 
worry,  and  for  nearly  two  years  a  good  deal  of  extra  financial 
strain.  During  this  time  he  has  had  at  intervals  what  he  calls 
nervous  attacks.  He  would  get  numb  in  his  feet  and  then  in  his 
legs,  and  a  sensation  would  rise  in  his  body  like  a  wave,  mak- 
ing him  cold  and  faint. 

Dr.  Purvis,  who  has  seen  him  in  the  spells,  says  they  are  evi- 
dently hysterical.    He  does  not  lose  consciousness. 

For  the  past  three  months  he  has  had  different  attacks,  con- 
sisting of  very  agonizing  pain  about  the  heart,  extending  to  the 
shoulders  and  down  the  arm  even  to  the  fingers,  very  frequently 
only  to  tlie  index  finger  and  thumb  of  the  left  hand.  They  have 
come  on  most  frequently  while  walking,  lie  catches  his  breath 
and  has  frequently  had  to  sit  down  on  a  doorstep.  He  describes 
the  pain  as  very  agonizing,  but  he  makes  no  mention  of  any 
sensation  like  that  of  impending  death.  Ilis  hands  get  cold; 
sometimes  the  feet  are  cold,  and  he  has  at  times  broken  out 
into  a  profuse  perspiration.  The  attacks  have  recurred  with 
great  frequency.  He  has  had  as  many  as  four  in  the  twenty- 
four  hours.  Worry,  overexertion,  and  on  several  occasions  a 
full  meal,  have  caused  attacks.  They  have  increased  rather 
than  diminished  during  the  past  month. 

The  patient  was  a  healthy-looking,  well-nourished  man, 
of  good  color,  of  fair  physinue,  with  black  hair  and  eyes.  The 
pulse  was  quiet  (80  a  minute),  tension  not  increased.  He  flushed 
easily,  and  there  was  the  most  marked  factitious  urticaria  and 
dermatographia.  The  apex-beat  was  not  visible  and  not  palpa- 
ble. The  superficial  cardiac  d  illness  was  not  increased.  The 
sounds  at  the  apex  were  clear.  There  was  no  accentuation  of  the 
aortic  secoiiu,  and  there  were  no  murmurs.  There  were  no 
painful  spots  about  the  pra^cordia.  The  patient  subsequently 
entered  the  private  ward  of  the  hospital,  where  he  had  several 
attacks  of  the  character  above  described. 

Case  VI. — On  May  23d  I  saw  at  the  Rennert  Hotel,  Dr. 
R.,  aged  thirty-three  years,  a  physician  from  one  of  the  North- 
ern cities,  who  had  had  a  series  of  most  severe  attacks  dating 
from  May  15th. 

The  patient,  a  man  of  very  high-strung,  nervous  organiza- 


PSEUDO-ANGINA  PECTORIS. 


97 


tion,  had  had  a  very  hard  battle  in  life,  overcoming  almost  in- 
superable physical  difticulties.  His  general  health  had  been 
very  good.  He  had  been  a  very  hard  student,  and  had  done 
much  work  outside  his  ordinary  professional  duties.  Three 
years  ago,  while  engaged  in  instructing  a  class,  he  felt  suddenly 
a  terrible  pain  in  the  heart,  and  a  numbness  extended  down 
the  left  arm  and  leg.  He  was  unable  to  stand,  but  did  not  lose 
consciousness.  He  recovered  from  this  attack  in  the  course 
of  an  hour  or  so,  and  had  no  recurrence  until  the  15th  of  the 
present  month.  At  5.30  p.  m.,  while  in  a  cab,  he  was  suddenly 
seized  with  an  agonizing  pain  just  below  the  left  nipple.  There 
were  numbness  and  tingling  in  the  left  arm  and  leg.  That  night 
the  pains  recurred,  and  from  his  wife's  account  he  evidently 
had  a  series  of  hysterical  attacks;  he  became  very  emotional, 
wept,  and  had  remarkable  delusions.  The  pain  was  of  such 
severity  that  he  had  to  have  morphine.  The  pulse  was  veiy 
variable,  and  at  one  time  became  extremely  rapid,  above  IGO. 
His  face  was  flushed,  not  pale. 

On  Sunday,  the  17th,  he  was  better,  and  on  Monday  he  was 
all  right  and  attended  to  his  practice.  On  Tuesday,  while  per- 
forming a  minor  operation,  he  had  a  recurrence  of  the  agoniz- 
ing pain.  He  said:  "Words  can  not  describe  my  torture, 
but  I  went  on  and  completed  the  operation." 

On  Tuesday  evening  he  had  another  severe  seizure,  and  had 
to  have  morphine  hypodermically,  and  took  chloral  and  bromide 
through  the  night. 

Ox.  Wednesday  he  was  in  very  bad  condition,  was  nervous, 
emotional,  and  quite  delirious.  On  Thursday  he  was  annoyed 
by  a  cabman,  and  had  an  attack  in  the  street,  which  upset  him 
very  much,  but  which  was  not,  however,  followed  by  delirium. 

Altogether,  in  the  past  eight  days,  he  has  had  five  or  six 
paroxysms  of  great  intensity.  In  the  attacks  his  wife  says  he 
is  very  restless,  gets  quite  beside  himself  with  the  pain,  and  de- 
mands morphine  at  once.  He  has  had  all  sorts  of  delusions, 
and  has  been  in  a  most  unnatural  mental  condition. 

Patient  was  very  healthy-looking,  evidently  very  high-strung 
and  nervous,  a  man  who  had  for  years  lived  far  too  intensely, 
and  had  worked  very  carelessly  and  with  too  much  friction. 


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98 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


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The  physical  examination  was  entirely  negative.  The  pulse 
was  quiet,  without  increase  in  tension.  The  heart  sounds  were 
clear,  without  accentuation  of  the  aortic  second.  The  vaso- 
motor system  was  extremely  labile,  and  the  slightest  scratch  was 
followed  by  an  active  reaction. 

The  persistence  of  pseudo-angina  is  sometimes  very  re- 
markable. In  1888  I  was  consulted,  in  Philadelphia,  by  an 
old  friend,  a  iDliysician  from  the  Province  of  (Quebec,  who 
had  very  severe  heart  disease.  While  I  was  visiting  him  late 
one  evening  at  the  Lafayette  Hotel,  lie  asked  me  to  step 
into  the  next  room  and  see  his  wife,  a  woman  sixty  years  of 
age,  Avhom  I  found  prostrate  on  the  bed  with  her  hands 
clasped  over  her  heart,  rocking  herself  from  side  to  side,  in 
an  agony  of  pain.  Her  hands  and  feet  were  cold,  the  face 
somewhat  flushed,  the  pulse  small  and  rapid.  I  could  not 
get  an  answer  from  her,  but  when  I  returned  to  the  room 
the  doctor  said  not  to  worry  (I  seemed  anxious  about  her), 
that  she  would  recover  in  a  little  while.  He  assured  me  that 
for  more  than  thirty  years  she  had  been  subject  to  these  at- 
tacks, particularly  when  overanxious  or  worried.  She  was  a 
very  nervous  woman,  had  been  hysterical  when  young,  and 
though  at  first  lier  husband  and  other  physicians  thought 
the  attacks  very  serious,  they  passed  off  so  quickly,  particu- 
larly under  the  influence  of  a  hot  whisky  punch,  that  he  had 
ceased  to  regard  them  as  in  any  way  dangerous. 

(h)  Yaso-motor  Angina.  —  Yaso-motor  phenomena  are 
rarely  absent  in  attacks  of  true  angina,  but  they  are  even 
more  pronounced  in  the  nervous  and  hysterical  subjects. 
Xothnagel  has  described  a  special  type,  angina  pectoris  vaso- 
motoria.^ In  the  four  cases  (all  men)  the  symptoms  con- 
sisted of  peculiar  sensations  in  the  extremities  or  on  one  side 

*  Deutsches  Archiv.  f.  klin,  Medicin,  Bd.  iii,  1867. 


L^. 


AXGINA  PECTORIS  VASO-MOTORIA. 


99 


of  the  body,  with  coklness  and  sometimes  lividity  of  the 
hands  and  feet  and  sweating.  AVith  this  there  were  palpita- 
tion of  the  lieart,  terrible  precordial  anxiety  or  pain,  and 
sometimes  feelings  of  faintness.  A  striking  feature  in  these 
eases  was  the  tendency  of  the  attacks  to  occur  in  the  cold, 
or  on  washing  the  hands  in  cold  water.  Xothnagel  regarded 
these  vaso-motor  phenomena  as  the  primary  features,  and 
the  cardiac  embarrassment  and  distress  as  secondary  to  a 
widespread  vaso-constrictor  influence  throughout  the  arterial 
system. 

A  good  deal  of  discussion  has  taken  place  upon  the  pro- 
l^riety  of  recognizing  this  as  a  special  type,  and  considering 
the  frequency  of  vaso-motoi*  changes  in  both  organic  and 
functional  forms  it  does  siem  doubtful;  and  yet  the  cases 
are  wonderfully  well  characterized  and  in  the  most  pro- 
nounced degree  always,  I  think,  of  the  functional  variety. 
In  a  large  proportion  the  vaso-constrictor  influences  dominate, 
and  there  is  pallor  with  coldness.  I  remember  but  one  in- 
stance in  which  the  vaso-dilator  phenomena  alone  were 
marked. 

In  1887  I  saw  (Case  YII),  in  Toronto,  a  lady,  aged  thirty- 
five  years,  stout,  well  nourished,  the  mother  of  five  or  six  chil- 
dren, who  had  been  the  subject,  at  intervals,  of  very  puzzling 
and  distressing  attacks.  Without  any  special  reference  to  the 
menstrual  period,  and  following  particulnrly  worry  or  excite- 
ment, she  would  experience  a  feeling  of  distress  about  the  heart 
amounting  to  actual  pain,  and  the  vessels  of  the  face  and  of 
tlie  extremities  would  become  congested,  and  she  felt  cold  and 
nimib.  But  much  more  distressing  than  these  were  the  sensa- 
tions of  great  pain  in  the  back  of  the  head  and  neck.  The  at- 
tacks would  last  for  twenty-four  hours  or  more,  and  were  some- 
times very  alarming.  I  could  not  gather  from  her  that  the  pains 
about  the  lieart  were  ever  of  a  very  agonizing  character,  but 
they  were  always  severe.    I  was  asked  to  see  her  to  determine 


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100 


ANGINA  PECTORIS  AND  ALLIET>  STATES. 


the  presence  or  absence  of  a  heart  lesion.  Both  sounds  seemed 
perfectly  clear,  and  there  were  no  signs  of  organic  disease.  I 
was  much  impressed  with  the  neurotic  condition  of  the  patient, 
and  suggested  hysteria.  I  saw  the  patient  in  an  attack,  evident- 
ly hysterical;  she  was  greatly  prostrated,  lay  with  the  eyes 
closed,  quite  livid  in  the  face,  and  the  hands  and  feet  were  pur- 
plish in  color  and  cold.  She  complained  of  great  distress  about 
the  heart  and  agonizing  pain  in  the  back  of  the  head  and  neck. 
The  subsequent  history  has  borne  out  the  view  taken  of  her 
case.  Within  a  year  or  so  she  got  perfectly  well  and  has  re- 
mained so,  not  having  had  an  attack  for  nearly  eight  years. 

Much  more  commonly  there  is  pallor  with  the  coldness. 
In  women  the  attacks  are  apt  to  recur  at  or  before  the  men- 
strual period. 

Mrs.  R  (Case  VIII),  aged  forty  years,  consulted  me  in 
1890  about  attacks  of  severe  pain  in  the  region  of  the  heart, 
which  had  recurred  at  intervals  for  eight  years,  since  the  birth 
of  her  last  child.  They  were  particularly  liable  to  come  on  dur- 
ing the  menstrual  period,  or  whenever  she  was  subject  to  any 
special  mental  strain  or  worry.  The  pains  were  very  severe,  im- 
mediately under  the  left  breast,  and  passed  up  the  neck  and 
down  the  left  arm.  She  did  not  flush  with  them,  but,  on  the 
contrary,  got  pale  and  felt  very  cold,  particularly  in  the  hands 
and  feet,  which  sometimes  sweated.  The  pains  were  not  con- 
tinuous, but  recurred  at  intervals  extending  over  a  period  of 
several  days.  Diet,  she  thinks,  had  no  special  i  ..'  ence.  She 
slept  badly  and  dreamed  a  great  deal.  The  patient  was  a  stout, 
well-nourished  woman  of  good  color;  the  pulse  was  regular, 
about  80;  the  arteries  wcxc  not  sclerotic.  There  was  no  heart 
disease. 

In  women,  as  you  will  have  noticed  in  the  reports  I  have 
read,  the  features  of  coldness  of  the  extremities  with  numb- 
ness and  pallor  are  very  common.  In  men  this  type  may  occur 
in  a  most  marked  degree,  and  the  diagnosis  may  be  for  some 
time  in  doubt. 


L  i 


ANGINA  PECTORIS  VASO-MOTORIA. 


101 


Case  IX. — A.  B.,  aged  forty-two  years,  seen  December  30, 
1895,  complaining  of  paroxysmal  attacks  of  terrible  intensity, 
characterized  by  a  feeling  of  suspended  animation,  as  though 
the  breath  had  left  the  body;  at  the  same  time  the  hands  and 
feet  get  cold,  and  there  is  a  sensation  of  stricture  about  the 
root  of  the  neck. 

The  patient,  who  occupies  a  prominent  position  of  trust, 
looks  a  healthy,  vigorous  man.  His  family  history  is  excel- 
lent. 

As  a  young  man  he  was  very  well.  He  has  never  had  syphi- 
lis; is  a  moderate  drinker,  and  has  used  tobacco  freely.  Seven 
years  ago,  following  a  period  in  wliich  he  was  very  much  over- 
worked, he  first  had  the  attacks,  which  recurred  for  nearly 
eighteen  months.  At  that  time  they  caused  him  great  alarm, 
but  with  the  exception  of  two,  they  were  not  very  severe.  The 
present  attacks  date  from  just  two  months  ago.  He  has  been 
in  his  usual  health,  and  knows  of  no  special  cause  why  they 
should  have  come  on.  A  majority  of  the  paroxysms  have  oc- 
curred at  night,  just  as  he  was  beginning  to  doze  to  sleep.  He 
has  had  tliem  also  on  the  street,  and  seven  years  ago  in  one  he 
had  slight  vertigo,  ..i.d  had  to  sit  down  on  some  steps,  and  he 
felt  as  he  sat  upon  them  as  though  they  were  rising  and  falling. 
The  attacks  may  come  on  while  he  is  sitting  at  his  desk,  or  while 
he  is  reading  quietly  in  his  chair.  Exercise  is  very  apt  to  bring 
them  on,  and  if  he  runs  for  a  car  or  hurries  upstairs  he  is  apt 
either  to  have  a  severe  attack  or  to  experience  a  chilly  feeling 
and  the  sensation  which  he  constantly  speaks  of  as  though  his 
breath  had  all  left  him. 

The  sensations  which  he  describes  in  the  attack  are  very 
curious.  He  lays  special  stress  on  the  feeling  that  the  respira- 
tion had  ceased,  and  it  gives  him  some  relief  to  draw  several 
deep  breaths.  With  this  is  associated  a  sense  of  great  stricture 
about  the  lower  part  of  the  neck,  and  a  terrible  sensation  about 
the  heart,  as  though  it  was  his  last  minute.  He  feels  strangely 
in  the  head,  and  thinks  he  has  a  very  wild  look.  The  face  be- 
comes pale,  the  hands  and  feet  get  cold  as  ice,  and  become  very 
clammy  with  perspiration,  and  in  several  attacks  he  has  had  a 
feeling  of  numbness  in  the  legs  from  the  knees  down.    He  lays 


f'i 


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I 


i 


102 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


very  great  stress  upon  the  sensation  of  coldness  in  the  arms 
and  legs,  and  says  that  on  one  occasion  he  took  a  warm  bath, 
and  even  though  the  water  was  quite  hot  he  still  had  a  feeling 
of  great  coldness  and  numbness  in  his  legs.  In  one  attack  the 
face  and  neck  became  very  red  and  congested,  and  the  nose  bled 
profusely.  There  is  invariably  palpitation  of  the  heart,  and  he 
has  been  told  by  his  doctor  that  the  pulse  at  the  wrist  becomes 
scarcely  perceptible.  In  a  paroxysm,  seven  years  ago,  he  thinks 
he  lost  consciousness  for  a  moment.  He  staggered  and  fell. 
In  one  attack  at  this  time  he  had  vertigo.  As  the  paroxysm 
passes  oit'  he  belches  a  great  deal  of  wind.  In  several  spells 
there  has  been  a  good  deal  of  itching  of  the  skin,  and  in  one 
or  two  a  marked  twitching  of  the  muscles.  The  duration  of 
the  entire  paroxysm  varies  from  two  or  three  to  ten  or  fifteen 
minutes.  He  linds  that  a  strong  drink  of  whisky  will  sometimes 
cut  short  an  attack.  In  the  two  months  since  they  recurred 
he  has  had  on  an  average  about  four  in  a  week.  They  have  not 
all  been  severe.  He  has  been  much  alarmed  about  them,  and  in 
several  of  the  attacks  both  he  and  his  wife  have  been  greatly 
terrified. 

Patient  was  a  tall,  well-grown,  healthy-looking  man.  There 
was  no  arcus  senilis;  the  pupils  reacted  readily  to  light.  The 
pulse  was  soft  and  full,  regular,  tension  low.  The  apex-beat 
was  just  within  the  nijiple  line,  not  forcible;  slight  throbbing 
in  the  vessels  of  the  nock.  The  percussion  note  was  everywhere 
clear;  there  was  no  increase  in  the  area  of  heart  dullness.  The 
heart  sounds  were  clear;  the  aortic  second  was  not  accentuated; 
the  breath  sounds  were  equal  on  both  sides;  there  was  no  dull- 
ness in  cither  interscapular  region,  and  no  bruit  in  the  course 
of  the  descending  aorta  (a  diagnosis  of  aneurysm  had  been 
made).  The  cervical  glands  were  not  enlarged.  The  examina- 
tion of  the  abdominal  organs  was  negative.  The  knee-jerks 
were  normal.  There  was  no  Komberg's  symptom,  and  the  pupil 
reflexes  were  active. 

January  1,  189(5.  The  patient's  wife  came  to-day  to  speak 
about  her  husband's  condition.  She  says  that  last  summer  he 
had  a  few  slight  attacks.  She  mentions  several  features  of  in- 
terest, particularly  the  suddenness  of  the  onset.    For  example. 


!!■! 


■!i, 


PSEUDO-ANGINA  PECTORIS. 


103 


rms 
ith, 
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he  will  awaken  from  a  perfectly  sound  sleep  in  a  most  alarming 
paroxysm,  and  his  hands  and  feet  will  become  cold;  the  face 
is  usually  pale,  and  the  heart  will  throb  most  forcibly.  Within 
a  minute  or  two  his  hands  will  become  as  wet  as  though  they 
had  been  dipped  in  water.  She  remembers  two  or  three  attacks 
in  which  the  face  became  quite  congested  and  ful  instead  of 
pale.  lie  is  greatly  terrified,  and  always  feels  that  he  is  going 
to  die.  "What  has  reassured  her  always  is  the  fact  that  within 
ten  or  twelve  minutes,  sometimes  less,  he  is  laughing  and  talk- 
ing, quite  free  from  pain.  She  does  not  think  that  he  has  been 
a  very  nervous  man,  and  he  has  not  had  any  special  worries. 

April  1,  1890.  For  the  past  two  months  this  patient  has 
been  very  much  bettor,  and,  as  he  tells  me,  has  almost  recovered 
from  his  attacks. 

June  1st.    He  has  not  had  an  attack  for  nearly  four  months. 

(f)  lieflex  Angina. — And  lastly,  in  addition  to  the  purely 
hysterical  and  vaso-niotor  forms,  there  are  cases  in  which 
the  angina  apjiears  to  be  excited  reflexl}',  either  from  pe- 
ripheral or  visceral  irritation.  You  will  find  an  interesting 
chapter  in  Iluchard  devoted  to  these  reflex  pseudo-anginas, 
and  he  has  collected  a  number  of  cases  from  the  literature. 
Tliere  are  instances  of  anginous  attack  following  a  cervico- 
brachial  neuralgia,  of  either  traumatic  or  spontaneous  origin. 
You  remember  in  the  histories  of  the  cases  of  true  angina 
how  insistent  many  patients  were  as  to  the  influence  of  diet. 
There  is  also  a  so-called  gastro-intestinal  form  of  pseudo-an- 
gina, in  which  attacks  follow  indigestion.  The  following  is 
the  only  instance  in  my  list  in  which  the  visceral  irritation 
appeared  to  induce  the  paroxysms,  or,  to  speak  more  cor- 
rectly, in  which  the  two  conditions  were  associated: 

Case  XII. — ]\riss  A.,  aged  twenty-two  years,  seen  April  4, 
1893,  complaining  of  severe  attacks  of  pain  in  the  region  of  the 
heart. 

She  belongs  to  a  nervous  family,  and  she  has  never  been 


m 


'     'M 


lali! 


Iu4 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


i 


i 


■m 


ill 


I 


I 


very  strong.  She  denies  having  had  hysteria.  Several  times, 
as  a  chihl,  she  had  slight  rheumatism,  and  three  years  ago  she 
was  hiid  up  with  a  more  acute  attack.  Several  members  of  her 
family  have  also  had  it.  For  years  she  has  been  subject  to  dys- 
pepsia, particularly  after  eating  too  many  sweet  things.  For  a 
year  or  more  she  has  had  occasional  attacks  of  i)ain  in  the  chest, 
coming  on  particularly  when  she  has  indigestion.  The  pains 
are  neuralgic  in  character,  chiefly  about  the  lower  part  of  the 
chest,  yet  sometimes,  to  use  her  own  expression,  "  they  fly  all 
over  her."  Lately  she  has  been  much  alarmed  by  the  occur- 
rence of  two  attacks  of  great  severity,  the  first  about  two  months 
ago  and  the  second  a  month  ago.  There  was  agonizing  pain 
in  the  region  of  the  heart  with  shortness  of  breath.  Both  were 
severe  enough  to  require  hypodermic  injections  of  morphine. 
The  pain,  so  far  as  she  could  localize  it,  was  in  the  left 
side,  in  the  region  of  the  heart,  not  in  the  abdomen.  On  both 
occasions,  though  the  severity  of  the  pain  was  only,  as 
she  said,  for  an  hour  or  so,  yet  for  two  or  three  days  after 
she  had  more  or  less  pain  and  distress.  On  both  occasions 
she  had  dyspepsia,  but  slie  hsd  not  been  specially  nervous 
or  run  down.  She  does  not  know  whether  she  got  pale  dur- 
ing the  attacks,  but  she  sweated  after  them.  She  takes  a  great 
deal  of  exercise,  but  has  never  had  an  attack  brought  on  by 
exertion. 

She  looked  a  nervous  girl  and  flushed  easily.  The  examina- 
tion was  negative,  with  the  exception  of  slight  dilatation  of  the 
stomach. 

II.  Toxic  Angina. — The  second  division  of  functional  or 
pseudo-angina  embraces  cases  due  to  the  abuse  of  tea,  coffee, 
and  tobacco,  substances  harmless  in  themselves,  but  which 
if  taken  in  excess  may  disturb  the  action  of  the  heart.  My 
experience  with  this  form  is  extremely  limited.  In  tea  or 
coffee  drinkers  I  have  never  seen  attacks  of  cardiac  pain  which 
could  be  called  angina ;  though  paroxysms  of  severe  palpitation, 
with  distress  about  the  heart  and  gasping  respiration,  are  not 
uncommon  in  nervous  women  much  addicted  to  tea.    Tobacco, 


i 


TOXIC  ANGINA  PECTORIS. 


105 


«s  a  rule,  produces  only  slight  and  transient  disturbance  of  the 
heart's  action,  but  which  may  culminate  in  attacks  of  angina. 
When  one  considers  how  universal  is  the  custom,  the  infre- 
quency  of  severe  heart  symptoms  in  users  of  tobacco  is  re- 
markable. I  pass  months  without  seeing,  in  hospital  or  con- 
sultation work,  an  instance  in  which  symptoms  of  any  kind 
are  due  to  it. 

You  all  know,  some  of  you  have  experienced,  the  acute 
toxic  symptoms  in  beginning  to  use  tobacco.  The  effects  of 
the  habitual  use  are  very  varied.  To  the  large  majority  of 
persons  the  habit,  in  moderation,  is  harmless,  to  mmy  i;  is 
beneficial.  Among  the  injurious  features  those  relating  to 
the  heart  are  perhaps  the  most  important,  certainly  they  are 
the  most  common.  There  are  three  groups  of  cases  of  so-called 
tobacco  heart: 

1.  The  IrritaUe  Heart  of  SmoTcers. — Palpitation,  irregu- 
larity, and  rapid  heart  action  are  very  common  symptoms, 
particularly  in  young  boys.  They  are  often  combined  with 
dyspepsia;  pain  is  not  a  special  feature.  There  may  be  slight 
enlargement  of  the  heart.  It  is  a  condition  readily  relieved 
by  stopping  the  use  of  the  weed.  Disturbance  of  rhythm  is 
the  most  constant  effect  of  tobacco,  and  intermittence  is  more 
common  than  either  slowing  or  hastening  of  the  heart's  action. 
Weakening  of  the  vagus  control  is  the  more  frequent,  though 
in  my  own  case  the  slightest  excess  in  the  use  of  tobacco 
causes  intermission  with  slowing,  not  increase  of  the  pulse- 
rate.  An  opposite  effect — great  rapidity  with  feebleness 
of  impulse — is  more  common,  and  may  develop  suddenly  in 
an  habitual  smoke». 

2.  Heart  Pain. — Sharp  shooting  pains  about  the  heart  are 
not  very  uncommon  in  persons  who  smoke  or  chew  too  much. 
They  may  occur  alone  without  disturbance  of  the  cardiac 
rhythm  or  without  the  intensity  and  associated  features  of 


1 


W 


I 


•fv 


106 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


?: 


an  attack  of  tobacco  angina.     The  following  is  a  good  illus- 
trative case; 

I.  B.,  aged  twenty-nine  years,  seen  ^March  2i,  1890,  com- 
plaining of  pain  in  the  region  of  the  heart  just  below  the  nipi)le. 
The  first  attack  was  four  or  five  years  ago,  and  it  has  recurred 
at  intervals  ever  since.  Sliortly  after  the  onset  his  physician 
suggested  that  it  might  be  due  to  tobacco;  and  wlicn  he  gave 
up  smoking  the  attacks  disappeared  altogether.  Since  he  re- 
sumed the  habit  they  have  recurred,  and  for  tlie  past  year  he  has 
had  them  more  frequently.  The  attacks  occur  at  night,  just 
after  he  has  fallen  asleep.  lie  is  awakened  with  a  severe  pain 
in  the  region  of  the  heart,  which  almost  takes  his  breath  away, 
and  makes  him  cry  out  at  once.  It  rarely  lasts  more  than  a 
minute  or  two.  The  heart's  action  is  not  increased.  He  never 
has  had  any  sweating  and  does  not  change  in  color,  nor  do  his 
hands  and  feet  become  cold.  lie  has  never  had  any  i)ain  down 
the  arm.  It  is  always  of  the  same  character,  sharp  and  stab- 
bing, just  below  the  nipple,  and  is  intense  enough  to  cause  him 
to  cry  out.  He  has  had  as  many  as  four  or  six  attacks  in  the 
twenty-four  hours.  In  the  daytime  the  pain  is  not  so  severe, 
and  the  spells  are  more  transient.  He  has  never  had  an  attack 
following  exertion,  and  neither  emotion  nor  errors  in  diet  have 
any  influence  upon  them. 

He  was  a  member  of  a  very  nervous  family.  He  was  himself 
a  healthy,  vigorous  man.  He  had  smoked  from  his  boyhood 
three  or  four  strong  cigars,  and  when  traveling,  five  or  six 
cigars  a  day.  He  felt  himself  that  the  tobacco  was  responsible 
for  the  pain.  He  was  a  healthy-looking  man,  a  little  pale.  The 
pulse  was  76,  regular,  and  without  increased  tension.  The  apex- 
beat  was  in  normal  situation;  the  heart  sounds  were  everywhere 
clear.  The  second  aortic  was  perhaps  a  little  accentuated. 
There  was  no  pain  on  pressure,  and  no  hypera3sthesia. 

He  was  advised  to  stop  smoking  altogether. 

3.  Tobacco  Angina. — I  have  seen  but  two  cases  in  which 
the  severe  paroxysms  of  cardiac  pain  appeared  to  be  due  to 
the  abuse  of  tobacco. 


M 


illii 


TOXIC  ANGINA  PECTORIS. 


107 


us- 


Dr. ,  of ,  ngod  thirty-five  years,  consulted  me  April 

13,  1891,  coinplaining  of  severe  pains  in  his  chest  and  of  nunih- 
ness  in  the  left  arm.  The  patient  has  a  very  gouty  history  on 
both  sides.  ]le  has  been  a  hard-working  practitioner,  has  been 
a  moderate  drinker,  and  has  used  tobacco  to  excess,  both  smok- 
ing and  chewing.  Four  years  ago,  when  he  had  been  smoking 
very  Ijeavily,  he  had  an  attack  of  pain  about  tlie  heart  and 
down  the  arm,  for  which  he  consulted  Dr.  Pepper.  lie  had 
very  little  trouble  again  until  six  or  seven  montlis  ago,  when 
the  attacks  recurred.  He  then  consulted  Dr.  DaCosta,  who 
said  that  he  was  gouty  and  without  organic  disease  of  the  heart. 
Irately  the  attacks  have  been  very  severe,  chiefly  under  the  left 
margin  of  the  sternum  and  reaching  down  the  arm,  which  be- 
comes numb  and  tingles.  He  has  never  had  an  attack  in  which 
there  was  a  sense  of  impending  dissolution.  The  patient  was 
a  healthy-looking  num;  the  pulse  was  78,  the  tension  a  little 
plus,  but  there  was  no  sclerosis  of  the  arteries.  The  examina- 
tion was  negative,  with  the  exception  that  the  aortic  second 
sound  was  perhaps  a  little  sharper  and  clearer  than  normal. 
He  was  told  that  he  had  no  heart  disease,  and  he  was  urged  to 
live  a  temperate  life,  to  give  up  tobacco,  and  ordered  ten  grains 
of  iodide  of  potassium  three  times  a  day.  After  seeing  him  the 
first  day  I  dictated  the  following  note: 

"  In  this  case  the  gouty  history  and  the  acientuated  second 
sound  are  perhaps  suggestive  of  true  angina.  On  the  other 
hand  he  has  been  a  very  heavy  smoker,  is  evidently  nervous 
and  worried  about  his  condition,  both  of  which  factors  must 
be  taken  into  consideration." 


Ill 


f  u 


I  have  seen  this  patient  at  intervals  during  the  past  five 
years.  lie  lays  very  great  stress  upon  tobacco  as  the  cause  of 
the  attacks,  and  any  indulgence  is  apt  to  be  followed  by  severe 
pain.  On  February  17,  1894,  in  a  letter  lie  laid  stress  again 
upon  the  part  played  by  tobacco;  in  a  letter  received  recently 
he  gives  a  very  satisfactory  account  of  himself,  though  he  still 
smokes,  and  still  has  attacks.  There  is  a  feature  in  this  case 
upon  which  Huchard  lays  a  great  deal  of  stress  in  tobacco  an- 


? 


108 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


\t^^. 


( 


gina — namely,  the  oeeurrciicc  of  ('ortaiii  not'turnal  spells  al- 
most like  syncope.  The  patient  states  in  the  recent  letter  that 
"  the  strangest  symptom  of  all  is  that  jnst  as  I  lose  myself,  and 
am  abont  to  drop  to  sleep,  and  often  jnst  after  losing  conscious- 
ness, r  choke,  sit  np  ([nickly,  and  feel  for  the  moment  as  if  *  the 
game  was  np.'  There  is  no  jjain,  no  excitement  of  the  heart, 
and  yet  this  often  occnrs  after  having  a  choking  fnlliiess  an<l 
distention  in  my  throat,  as  if  I  was  trying  to  force  a  great 
volnme  throngh  a  small  s})ace."  lie  adds,  "  Sndden  inhala- 
tions of  tobacco  smoke  still  give  me  pain  about  the  heart,  last- 
ing for  several  nunutes." 

T.  AV.,  aged  forty-five  years,  seen  with  Dr.  Goldsborough 
June  la,  1895. 

The  patient  was  a  very  vigorous,  healthy-looking  man,  and 
has  enjoyed  uniforndy  good  health.  In  Xovember,  18i)4,  he 
had  infiuenza  and  was  wretched  for  two  months  after  it.  He 
]iad  been  a  heavy  smoker  since  his  fourteenth  year.  Some  years 
ago  ho  gave  up  the  habit  for  twelve  months,  as  he  had  attacks 
in  bed  in  which  he  felt  as  though  ihe  heart  had  stopped  and  he 
would  have  to  jump  out  of  bed  and  gasp  for  breath.  He  got 
well  and  has  smoked  heavily  ever  since. 

On  the  Gth  of  January  he  had  a  suddo'i,  severe  paroxysm, 
to  which  he  attributes  his  present  nervous  condition.  He  had 
been  smoking  on  an  average  twelve  strong  cigars  a  day.  The 
attack  began  with  a  pecidiar  feeling  in  the  chest,  not  exactly 
pain,  but  great  distress.  He  turned  pale,  belched  gas  con- 
stantly, perspired,  was  cold,  could  not  lie  down,  and  felt  as 
though  he  was  going  to  die.  He  had  no  agonizing  pain,  but  he 
felt  a  sense  of  terrible  oppression,  and  had  numbness  in  both 
hands  and  wrists.  The  heart's  action  during  this  attack  was 
scarcely  perceptible,  the  pulse  very  feeble  and  fluttering.  It 
lasted  altogether  two  or  three  hours,  and  alarmed  him  very 
much.  For  several  days  afterward  he  felt  prostrated  and  weak, 
and  for  a  month  he  had  a  sort  of  faint  feeling,  particularly 
after  eating.  These  faint  attacks  have  distressed  him  very  much. 
They  would  come  on  at  intervals  and  he  would  turn  pale  and 


TOXIC  ANGINA  PECTORIS. 


109 


sweat  profusely.  lie  never  lins  ncluall}  fainted  in  them,  but  one 
(lay  in  the  barber's  chair  he  very  nearly  lost  eonsciousness. 
They  recurred  for  about  two  months  after  his  severe  attack. 
JIc  has  been  very  nervous  and  uneasy  about  himself,  and  has 
been  K''*^''t'y  worried.  He  has  stopped  tobacco  since  Janu- 
ary (1th. 

1'he  paiient  was  n  robust-lookinj;  man  of  good  color.  There 
was  no  arteriosclerosis.  'J'he  apex-beat  was  within  the  nip{)le 
line,  visible,  readily  felt,  of  normal  intensity.  There  was  no 
increase  in  the  cardiac  dullness.  'J'he  lieart  sounds  were  clear, 
and  there  was  no  accentuation  of  aortic  second.  Tiiere  was  no 
enlargement  of  either  liver  or  spleen. 

Up  to  April  17,  189(1,  when  last  heard  from,  this  patient 
had  had  no  return  of  the  attacks,  and  had  been  quite  well. 


As  my  cxpenonce  of  tliis  form  has  been  so  limited,  I  will 
read  you  Iluchard's  statements  as  to  the  chief  characters  of 
tobacco  angina: 

1.  "  Angina  pectoris  due  to  tobacco  assumes  often  the 
vaso-niotor  type  (extreme  pallor  of  the  face  with  vertigo,  con- 
traction of  the  pulse,  tendency  to  syncope,  pnocordial  anx- 
iety with  or  without  pain,  chilling  of  the  extremities,  cold 
sweats). 

2.  "  The  attack  of  angina  is  often  associated  with  other 
manifestations  of  nicotine  poisoning:  vertigo,  ringing  in  the 
ears,  dysphagia,  headache,  a  sense  of  suiTocation  and  dysp- 
noea (nicotine  asthma),  sensations  of  general  Aveakness,  of 
cerebral  confusion,  of  spinal  hyperrpsthesia,  troubles  of  vision, 
etc.  These  symptoms  may  be  dissociated  from  the  paroxysms 
and  observed  separately. 

3.  "  Those  suffering  from  tobacco  angina  show,  almost 
always,  apart  from  or  during  the  course  of  their  attacks, 
disturbances  in  the  heart's  function:  slowing  with  cnfeeble- 
ment  of  the  heart's  beat,  tachycardia  or  bradycardia,  inter- 
missions, arrhythmia,  palpitation,  tendency  toward  lipothy- 


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1               ; 

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n 


110 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


mia  or  syncope,  attacks  of  palpitation  with  extreme  irregu- 
larity of  tlie  heart  {folie  cardiaque,  delirium  cordis). 

4.  "  The  attacks  of  angina  are  often  very  painful  and 
complete  in  their  intensity  and  in  the  radiation  of  the  pains. 
But  it  is  in  angina  from  tobacco  that  one  sees  particularly  the 
imperfect  and  abortive  forms,  consisting  of  dyspnoea  with 
slight  praacordial  anxiety,  or  simply  of  a  little  sense  of  uneasi- 
ness behind  the  sternum,  with  the  sensation  of  stopping  of 
the  heart  and  the  fear  of  impending  death. 

5.  "  Angina  from  tobacco  shows  generally  spontaneous 
paroxysms;  they  may  also  be  produced  by  exercise  or  exer- 
tion. It  has  then  the  clinical  characters  of  angina  from 
coronary  artery  disease. 

G.  "  The  paroxysms  of  functional  tobacco  angina  due  to 
spasmodic  contractions  of  the  coronaries  disappear  rapidly 
after  the  complete  stopping  of  tobacco,  a  clinical  feature 
common  to  almost  all  the  symptoms  of  tobacco  poisoning 
without  lesions. 

7.  "  This  is  not  true  of  the  paroxysms  of  organic  tobacco 
angina  due  to  organic  contraction  of  the  coronaries  (through 
nicotine  arterio-sclerosis).  This  form  is  more  resistant;  it 
disappears  but  slowly,  or  may  be  permanent;  it  is  worthy 
of  treatment  with  iodide  of  potassium. 

8.  "  There  exists  another  form  of  stenocardia,  the  most 
benign  of  all ;  it  is  due  remotely  but  not  immediately  to  nico- 
tine; it  follows  dyspepsia  produced  by  the  abuse  of  tobacco; 
it  is  cured  by  the  removal  of  tobacco  f.iid  the  disappearance 
of  the  dyspepsia." 


i 


11' 


nd 

|ns. 

tlie 

litli 

isi- 

of 


LECTUEE  VI. 


THEORIES  OF  ANGINA. 


The  importance  of  coronary  artery  disease. — Intermittent  claudication. — 
State  of  the  heart  muscle  in  an  attack. — Seat  and  cause  of  the  pain. — 
Vaso-motor  changes  in  angina. — Relations  of  spurious  and  true  angina. 

Coronary  Artery  Disease  and  Angina. — It  would  be 
impossible  to  discuss,  even  briefly,  all  of  the  theories  which, 
from  time  to  time,  have  been  offered  in  explanation  of  this 
remarkable  group  of  symptoms.  Huchard  has  tabulated 
sixty-one  opinions  under  six  main  theories!  Under  these  cir- 
cumstances it  will  be  wise  to  start  out  with  the  statement  of 
a  generally  accepted  fact — viz.,  that  in  an  immense  propor- 
tion of  all  cases  angina  pectoris  vera  is  associated  with  disease 
of  the  coronary  arteries  and  of  the  myocardium.  This,  you 
will  recall,  was  Jenner's  original  suggestion,  which  he 
enounced  in  the  letter  I  read  to  you  in  Lecture  I.  Very 
shortly  after  the  appearance  of  Heberden's  paper  the  first 
reports  of  coronary-artery  disease  in  angina  were  made  by 
Fothergill — the  great  Fothergill,  whose  friendship  with  Rush 
and  whose  interest  in  the  medical  affairs  of  the  American 
colonies  endeared  his  name  to  the  profession  on  this  side  of 
the  Atlantic.  In  the  first  case  which  he  reports  there  is  no 
note  upon  the  coronary  arteries,  but  "  on  the  outward  mus- 
cular part  (of  the  heart)  near  the  apex  was  a  small  white  spot 
as  big  as  a  sixpence,  resembling  a  cicatrix,"  evidently  a  patch 

of  fibroid  myocarditis.    In  another  case  (which  seems  really 

111 


I: 


fl  ^ 

(                                              ;J 

i 
1 

i 

j      1 

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.  i 

m 

in 


112 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


to  have  been  one  of  angina  sine  doloi'e)  the  patient,  who  had 
a  difficulty  or  incapacity  to  walk  up  a  moderate  ascent,  died 
in  a  sudden  transport  of  anger.  John  Hunter,  who  made  the 
dissection,  found  "  the  two  coronary  arteries,  from  their  ori- 
gin to  many  of  their  ramifications  upon  the  heart,  were  be- 
come one  piece  of  bone."  *  The  older  rejiorts,  which  cor- 
roborated the  opinion  of  Jenner,  are  to  be  found  in  Parry's 
monograph;  while  the  full  statistics  on  the  (piestion  have 
been  collected  with  great  pains  by  Iluchard.  In  a  supple- 
mentary chapter  to  his  work  you  will  find  a  sunmiary  of  145 
autopsies  in  cases  of  angina,  gathered  from  the  literature. 
In  17  cases  there  was  mention  only  of  a  lesion  of  the  coro- 
naries  without  further  specification;  of  128  there  wore  G8 
with  lesions  of  both  coronary  arteries,  37  of  the  left  vessel, 
15  of  the  right,  and  in  12  the  seat  of  the  lesion  was  not  stated. 
In  the  128  cases  obliteration  or  stenosis  of  the  vessels  had 
occurred,  and  of  these  in  121  there  was  atheromatous  nar- 
rowing or  thrombosis,  in  5  embolism,  and  in  2  compression. 
Fatal  cases  are  on  record  in  which  the  coronary  arteries  have 
been  found  normal;  most  of  these  are  instances  of  adherent 
pericardium  or  valvular  disease.  There  are  also  fatal  cases 
of  tobacco  and  post-febrile  angina  in  which  the  anatomical 
condition  is  stated  to  have  been  negative.  Xothing  is  easier 
than  to  overlook  myocardial  changes,  particularly  in  the  older 
methods  of  examination,  and  a  heart  may  present  extensive 
fibroid  disease  with  obliteration  of  arteries,  which  to  the  un- 
trained eve  looks  health v,  or  which  mav  not  show  anv  coarse 
lesions  of  the  aorta,  or  of  the  main  branches  of  the  coronary 
vessels.  Or  again,  Krehl's  method  of  serial  section  may  show 
extensive  myocarditis,  with  changes  in  the  smaller  arteries, 
in  a  heart  apparently  normal.    Spasm  of  the  coronary  arteries 

•  Medical  Observations  and  Inquiries,  vol.  v,  1774. 


f'-i 


THEORY  OF  INTERMITTENT  CLAUDICATION.  113 


m 


has  been  invoked  to  explain  the  sudden  death  in  these  cases, 
but  it  is  much  more  likely  that  changes  of  a  serious  nature 
were  overlooked  (as  from  personal  experience  I  know  they 
often  are)  in  the  ordinary  methods  of  examination.  Ischaemia, 
a  condition  in  which  the  heart  muscle  is  imperfectly  supi)lied 
with  blood,  is  the  main  factor  in  all  coronary  lesions,  whether 
narrowing  of  the  orifices  of  the  arteries,  atheroma  of  their 
walls,  or  thrombosis  or  embolism  of  their  channels. 

In  seeking  to  explain  the  relation  of  the  arterial  and  myo- 
cardial changes  to  the  symptoms  of  angina  we  pass  at  once 
into  the  region  of  speculation.  On  turning  to  the  thera- 
peutical indexes  and  finding  a  list  of  twenty  or  more  drugs 
recommended  in  a  given  disease  you  may  be  quite  safe  in 
concluding  that  our  knowledge  of  the  treatment  of  the  affec- 
tion is,  to  say  the  least,  imperfect;  and  so,  when  you  read  the 
tabular  list  of  the  theories  of  angina,  covering  nearly  four 
pages  of  Iluchard's  Traite,  you  may  feel  assured  that  the  last 
word  has  not  yet  been  said  upon  the  subject. 

Theory  of  Ixtermittent  Claudication. — The  view 
which  is  based  most  directly  on  the  coronary-artery  disease  is 
one  which,  as  I  shall  tell  you,  dates  really  from  the  early  part 
of  the  century,  and  finds  its  explanation  in  the  remarkable 
phenomenon  known  as  intermittent  claudication.  Bouley,* 
Sr.,  the  celebrated  French  veterinarian,  described  an  affec- 
tion in  the  horse,  in  which,  after  being  driven  for  fifteen  or 
twenty  minutes,  the  animal  stops,  the  hind  legs  get  stiff,  and 
soon  it  is  unable  to  stir.  It  may  fall  down,  and  apparently 
be  in  great  suffering.  In  from  half  an  hour  to  an  hour  it 
will  recover  and  will  go  on  comfortably  for  another  fifteen 
minutes,  and  then  an  attack  recurs.  In  such  cases,  post  mor- 
tem, the  artery  of  the  affected  limb  has  been  found  blocked 


111 


*  Nouveau  dictionnnire  pratique  de  viedecine,  de  chirurgie  et  d'hygUne 
vSterinaires.    Tome  deuxiurae,  p.  540.    Bouley  and  Renault,  1856. 


114 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


with  a  clot,  or,  when  both  hind  logs  have  been  involved,  the 
abdominal  aorta  has  contained  a  thrombus. 

Charcot,  while  an  interne  in  the  service  of  Rayer,  de- 
scribed in  man  a  condition  corresponding  to  this  intermittent 
claudication  in  the  horse.  He  says  *  that  one  day  a  jjatient 
in  the  service  told  him  that  he  was  not  able  to  walk  for  more 
than  a  quarter  of  an  hour  without  being  taken  with  cramps 
in  the  legs.  After  resting  a  while  he  would  get  better,  and 
would  be  able  to  resume  his  walking,  and  then  a  crisis  re- 
curred. At  the  autopsy  Charcot  found  a  ball  encysted  in  the 
neighborhood  of  the  iliac  artery,  and  a  traumatic  aneurysm 
which  had  obliterated  the  artery  in  its  lower  part.  The  cir- 
culation was  carried  on  by  collateral  channels,  which  were 
ample  to  maintain  the  nutrition  while  the  patient  was  quiet, 
and  for  a  short  period  during  exertion,  but  after  a  time,  when 
the  limbs  were  fatigued  by  the  movements,  the  quantity  of 
blood  which  reached  them  was  insufficient,  causing  a  relative 
isclia»mia,  with  tingling,  cramps,  and  impossibility  of  walk- 
ing. He  refers  to  the  fact  that  the  condition  is  often  pre- 
liminary to  gangrene,  and  narrates  a  case  in  which  a  patient 
with  the  affection  had  his  leg  amputated  for  gangrene,  f 

The  credit  of  pointing  out  the  analogy  between  this  con- 
dition and  angina  pectoris,  which  is  ascribed  usually  to  Potain 
(1870),  but  which  is  maintained  by  Weber  jf.  to  be  due  to 
Brodie  (1846),  belongs  in  reality  to  Allan  Burns,  whose  Ob- 
servations on  Some  of  the  Most  Frequent  and  Important  Dis- 
eases of  the  Heart  (1800)  is  a  well-known  storehouse  of  inter- 

*  Lemons  du  Mardi.    Tome  i,  p.  45, 

f  Charcot  seems  to  have  felt  hurt  that  his  communication  on  so  remark- 
able a  phenomenon  had  not  received  any  attention.  He  says:  "  Je  n'ni  pas 
encore  rencontre,  chose  singuliere,  car  mon  memoire  de  1856,  presento  i\  la 
Societe  de  Biologic,  n'est  pourtant  pas  ecrit  en  chinois,  il  me  parait  ecrit  en 
f ran9ais,  presque  en  bon  fran^ais,  je  n'ai  pas  rencontre,  dis-je,  un  seal  medo- 
cin  qui  nit  tenu  compte  de  mes  observations." 

J  American  Journal  of  the  Medical  Sciences,  May,  1894, 


THEORY  OF  INTERMITTENT  CLAUDICATION. 


116 


csting  facts.  Since,  so  far  as  I  know,  this  distinguished  writ- 
er's connection  with  this  supposed  new  theory  has  not  been 
pointed  out  (except  in  the  second  edition  of  my  Practice^ 
I  will  read  to  you  in  full  what  he  says  on  the  subject:  "  Such 
a  state  of  the  arteries  of  the  heart  [referring  to  atheroma] 
must  impair  the  function  of  that  organ.  It  has  been  long 
known,  that  although  the  heart  is  always  full  of  blood,  yet 
it  can  not  appropriate  to  its  own  wants  a  single  particle  of 
fluid  contained  in  its  cavities.  On  the  contrary,  like  every 
other  part,  it  has  peculiar  vessels  set  apart  for  its  nourish- 
ment. In  health,  when  we  excite  the  muscular  system  to 
more  energetic  action  than  usual,  we  increase  the  circulation 
in  every  part,  so  that  to  support  this  increased  action  the  heart 
and  every  other  part  has  its  power  augmented.  If,  however, 
wo  call  into  vigorous  action  a  limb  round  which  we  have 
with  a  moderate  degree  of  tightness  applied  a  ligature,  we 
find  that  then  the  member  can  only  support  its  action  for  a 
very  short  time,  for  now  its  supply  of  energy  and  its  expendi- 
ture do  not  balance  each  other;  consequently,  it  soon,  from 
a  deficiency  of  nervous  influence  and  arterial  blood,  fails  and 
sinks  into  a  state  of  quiescence.  A  heart,  the  coronary  ves- 
sels of  which  are  cartilaginous  or  ossified,  is  in  nearly  a  similar 
condition ;  it  can,  like  the  limb  begirt  with  a  moderately  tight 
ligature,  discharge  its  functions  so  long  as  its  action  is  mod- 
erate and  equal.  Increase,  however,  the  action  of  the  whole 
body,  and  along  with  the  rest  that  of  the  heart,  and  you  will 
soon  see  exemplified  the  truth  of  what  has  been  said,  with  this 
difference,  that  as  there  is  no  interruption  to  the  action  of  the 
cardiac  nerves,  the  heart  will  be  able  to  hold  out  a  little  longer 
than  the  limb. 

"  If  a  person  walks  fast,  ascends  a  steep,  or  mounts  a  pair 
of  stairs,  the  circulation  in  a  state  of  health  is  hurried,  and 
the  heart  is  felt  beating  more  frequently  against  the  ribs  than 


.  i 

i; 


i-' 


■J- 


5 


116 


ANGINA  PECTOEIS  AND  ALLIED  STATES. 


usual.  If,  however,  a  person,  with  the  nutrient  arteries  of 
the  heart  diseased  in  such  a  way  as  to  impede  the  progress  of 
the  blood  along  them,  attempt  to  do  the  same,  he  finds  that 
the  heart  is  sooner  fatigued  than  the  other  parts  are,  which 
remain  healthy.  AVhcn,  therefore,  the  coronary  arteries  arc 
ossified,  every  agent  capable  of  increasing  the  action  of  the 
heart,  such  as  exercise,  passion,  and  ardent  spirits,  must  be  a 
source  of  danger." 

Burns  discusses  also  whether  the  paroxysm  was  depend- 
ent on  a  state  resembling  paralysis,  or  on  a  spasmodic  con- 
traction of  the  fibres  of  the  heart.  lie  hardly  thinks  that  the 
view  of  spasm  is  corroborated  by  any  analogous  facts  in  the 
animal  economy.  lie  says:  "  Do  we  ever,  after  the  operation 
for  aneurj'sm,  see  the  muscles  in  a  state  of  rigid  action;  or, 
when  we  apply  the  tourniquet  only  so  tight  as  to  impede  the 
circulation,  do  we  ever  observe  that  the  member  is  affected 
with  spasm?  In  both  cases  W'e  witness  an  induction  of  an 
extreme  degree  of  debility,  and  we  hear  the  person  complain- 
ing of  an  unusual  painful  feeling  in  the  limb,  but  still  its 
muscles  are  in  a  state  of  inactivity.  If  these  be  the  phenomena 
resulting  from  a  deficiency  of  arterial  blood  in  the  muscular 
system  in  general,  why  should  the  heart  be  an  exception? 
We  know  that  this  organ  is  principally  composed  of  muscle, 
and  we  have  therefore  reason  to  believe  that  it  is  regulated 
by  the  same  laws  wdiich  govern  other  muscles." 

I  will  read  you  this  intennittent  claudication  theory  as 
formulated  by  Potain,  in  1870,  and  you  will  see  how  com- 
pletely the  distinguished  clinician  of  La  Charite  has  been 
anticipated  by  the  old  Glasgow  professor:  "  If  one  considers 
the  painful  sensations,  the  disorders  of  the  cardiac  action, 
w'hich  constitute  an  attack  of  angina  pectoris;  if  one  but 
remembers  that  these  paroxysms  occur  always  after  fatiguing 
movements,  muscular  efforts,  or  emotional  disturbances — that 


THEORY  OF  INTERMITTENT  CLAUDICATION. 


117 


;s  of 
ss  of 
that 
^liicli 
8  are 
the 
be  a 


or. 


is  to  say,  under  conditions  in  which  the  heart  is  compelled  to 
contract  more  frequently  and  to  do  more  work;  if  one  con- 
siders finally,  that  repeatedly  some  narrowing  or  ossification 
of  the  coronary  arteries  has  been  found  in  the  bodies  of  vic- 
tims of  this  disease;  if  one  considers  these  facts,  it  will  ap- 
pear in  every  way  probable  that  the  heart  does  not  escape 
from  the  common  law,  that  it  also  becomes  rapidly  exhausted 
when  its  arteries  can  no  longer  give  it  the  quantity  of  blood 
r.^^ccssary  for  its  increased  activity;  and  that  then  it  becomes 
the  seat  of  painful  disorders,  just  as  in  the  case  of  the  muscles 
of  the  lower  extremity.  Herein  lies  a  principle  which  may 
be  briefly  expressed  as  follows:  The  symptoms  caused  by 
ischaemia  become  exaggerated  whenever  the  diseased  organ 
becomes  active,  because  of  the  increased  quantity  of  blood 
which  this  activity  demands."  * 

It  is  easy  to  suppose  that  a  narrowing  of  the  orifices  of 
the  coronary  arteries,  or  of  the  lumen  of  a  main  branch,  can 
bring  about  conditions  most  favorable  for  the  production  of 
this  intermittent  claudication — ^.  <?.,  a  state  in  /hich,  so 
long  as  the  heart  is  acting  quietly,  sufficient  blood  reaches 
its  muscle;  but  if  called  upon  to  act  more  forcibly,  by  exer- 
tion or  emotion,  the  larger  supply,  then  needful  to  maintain 
the  nutrition,  might  not  be  forthcoming,  with  the  result  of 
a  relative  ischrcmia  and  disturbance  of  function. 

What  is  the  condition  of  the  heart  muscle  in  this  ischae- 
mia  ?  Is  it  likely  to  be  the  same  in  the  narrowing  of  atheroma 
and  in  the  blocking  from  thrombosis  and  embolism?  How 
shall  we  account  for  the  remarkable  disparity  between  the 
incidence  of  angina  pectoris — a  rare  affection — and  the  inci- 
dence of  coronary-artery  disease — an  everyday  degeneration 
in  persons  above  the  age  of  sixty?    With  what  special  condi- 


sw- 


11 


•  Quoted  by  Huchard. 


r 

1 

1 

» ' 
)'' 

fl, 


118 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


tions  is  the  pain  associated  and  what  relation  have  the  pains 
of  pseudo-angina  to  those  of  the  angina  vera?  What  part  do 
vaso-iuotor  changes  play  in  the  process^  These  are  among 
the  questions  which  must  be  asked  and  answered  before  wo 
can  accept  the  intermittent  claudication  or,  indeed,  any 
other  theory.  We  may  discuss  these  points  under  three  heads: 
the  state  of  the  heart  muscle,  the  scat  and  cause  of  the  pain, 
and  the  vaso-motor  changes  in  the  disease. 

I.  The  State  of  the  IIeakt  Muscle. — During  an  attack 
the  organ  has  been  sui)posed  to  be  either  in  spasm,  or  in  a 
condition  of  paralysis,  from  imperfect  blood  supply  or  over- 
distention.  Ileberden,  and  many  since,  have  regarded  the 
heart  in  a  paroxysm  as  in  spasm  or  cramp;  but  Allan  Burns, 
and  after  him  Brodie  (as  quoted  by  Weber),  urge  against  this 
view  that  the  muscles  in  the  condition  following  blocking  of 
arteries  are  not  in  spasm,  but  rather  the  opposite;  and,  while 
not  absolutely  paralyzed,  are,  as  Brodie  says,  in  a  state  ap- 
proaching to  it.  With  this  the  clinical  features  of  the  attack 
are  in  accord,  for  although  it  has  been  noted  in  exceptional 
instances  that  the  pulse  beat  has  not  been  feeble  or  the  car- 
diac rhythm  disturbed,  the  general  experience  is  that  the  left 
ventricle  is  weakened  and  the  systemic  arteries  imperfectly 
filled. 

The  condition  of  the  heart  muscle  in  the  attack  is  prob- 
ably not  always  the  same.  For  example,  in  a  patient  with 
ten  or  fifteen  paroxysms  daily  we  can  not  suppose  that  any 
serious  organic  change,  as  anopmic  necrosis,  develops  in  each 
attack.  In  such,  as  Allan  Burns  says,  "  the  supply  of  energy 
and  expenditure  do  not  balance  each  other  " ;  "a  heart  with 
the  coronary  arteries  cartilaginous  or  ossified  can  discharge  its 
functions  so  long  as  its  action  is  moderate  and  equal,  but  if 
the  circulation  is  hurried,  the  progress  of  the  blood  along  the 
nutrient  arteries  of  the  heart  is  impeded  and  the  heart  be- 


THE  STATE  OP  THE  HEART  MUSCLE. 


119 


pains 
rt  (Jo 
moiig 
e  wo 
any 
eads : 
pain, 


comes  fatigued."  A  transient  paresis  from  insufficient  supply 
of  oxygenated  blood  (and  possibly,  as  has  been  suggested, 
from  a  sort  of  auto-intoxication  with  the  products  of  imper- 
fect metabolism)  explains  the  cardiac  weakness  and  the  tend- 
ency to  syncope,  but  affords  not  the  slightest  clew  to  an  ex- 
planation of  the  main  feature  of  the  attack — the  pain.  Very 
different  to  this  relative  ischcemia  of  the  cardiac  muscle  must 
be  the  condition  following  the  blocking  of  a  large  branch  by 
a  thrombus  or  an  embolus.  The  resulting  anasmic  infarct, 
if  at  all  extensive,  must  cause  not  alone  great  weakness  of 
the  cardiac  nmscle,  but  at  the  site  of  the  lesion  the  smooth 
uniformity  of  the  waves  of  contraction  must  be  seriously 
interrupted.  This  cardiomalacia  may  lead  to  ruiJture  of  the 
wall  of  the  ventricle  (eleven  cases  in  Huchard's  collection  of 
autopsies)  or  may  cause  pericarditis.  While  the  ansemic  in- 
farct is  a  well-recognized  lesion  in  fatal  cases  of  angina  pec- 
toris, it  must  be  remembered  that  a  paroxysm  of  pain  is  really 
a  rare  complication  of  this  not  infrequent  change.  It  is  in- 
teresting to  note  that  the  scars  of  infarcts  have  been  found 
years  after  recovery  from  attacks  of  angina.  Curschmann,  in 
the  discussion  at  the  Congress  f.  innere  Medicin,  already  re- 
ferred to,  mentioned  two  cases,  one  a  man  of  seventy-five 
years,  the  other  a  woman  of  sixty,  both  of  whom,  some  twenty 
years  before  death,  had  had  severe  attacks  of  angina  from 
which  they  recovered  with  bradycardia.  There  were  found 
old  fibroid  changes  in  the  myocardium  with  obliteration  of 
branches  of  the  left  coronary  arteries.  We  may  say,  then, 
that  the  evidence,  such  as  it  is,  favors  the  view  that  the  heart 
muscle  in  the  attack  is  in  a  state  of  paresis.  This,  however, 
may  not  be  general;  it  may  be  confined  to  the  left  ventricle 
or  to  a  part  of  its  wall;  but  weakness  in  itself  offers  not  the 
slightest  clew  to  the  cause  of  the  pain. 

The  view  of  Heberden  that  the  heart  muscle  during  the 


120 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


I 


■! 


attack  is  in  a  state  of  spasm  lias  been  supported  by  many 
writers,  notably  by  Latham.  The  existence  of  spasm  of  the 
heart  during  life  can  not  be  inferred  from  the  empty  and 
contracted  condition  of  the  left  ^'entriclc  post  mortem.  Kcla- 
tive  ischwmia  in  the  territory  of  one  coronary  artery  or  of 
its  main  branch,  still  more  an  area  of  anicmic  necrosis,  might 
readily  bring  about  conditions  favoring  cramp,  not  necessarily 
in  the  affected  region  (very  unlikely,  indeed,  in  an  infarct), 
but  in  contiguous  muscular  districts,  the  rhythm  of  whose 
motion  would  be  interrupted  and  disturbed.  I  do  not  know 
of  cramp  in  ilie  voluntary  muscles  produced  under  analogous 
conditions,  but  I  may  remind  you  of  the  horribly  painful 
cramps  in  the  legs  in  the  exhaustion  following  the  prolonged 
use  of  untrained  muscles,  and  the  cramps  in  the  calves  and 
feet  in  chronic  arterio-sclerosis.  Pain,  the  special  feature  of 
the  angina  attack,  is  explained  by  the  cramp  theory.  The 
most  intense  suffering  which  can  be  experienced  is  associated 
with  muscular  contractions  of  the  tubular  structures,  as  in 
intestinal,  biliary,  and  renal  colic,  and  in  the  contractions  of 
the  uterus  in  parturition.  And  observe  that  this  agonizing 
pain  is  in  parts  not  endowed,  so  far  as  we  know,  with  very 
acute  sensibility.  Theoretically  there  is  much  in  favor  of 
the  idea  that  in  the  most  powerful  muscular  organ  of  the 
body  irregular  cramplike  contractions,  even  if  localized,  might 
be  accompanied  by  painful  sensations,  which  could  attain 
the  maximum  intensity  present  in  an  angina  attack.  But  this 
brings  us  directly  to  a  discussion  of 

II.  The  Seat  and  Cause  of  the  Pain  in  Angina. — 
There  is  one  inexplicable  feature  which  baffles  all  suggestion, 
and  gives  us  pause  in  an  uneasy  apprehension  lest  we  should 
know  even  less  than  we  suppose.  I  refer  to  the  extraordinary 
variability  in  the  incidence  of  attacks  in  cardio-vascular  lesions 
apparently  most  favorable.    Why  should  true  angina  pectoris 


SEAT  AND  CAUSE  OF  THE  PAIN. 


121 


In 


be  so  rare  in  hospital  patients,  and  so  rare  in  women?  There 
must  be  some  peculiar  state  of  the  nervous  system,  some  un- 
due susceptibility,  as  Sir  Kichard  (^uain  says,  which,  in  the 
presence  of  certain  conditions,  is  really  the  essential  factor. 
Like  epilepsy,  to  which  it  has  been  compared  by  Trousseau, 
and  more  recently  by  B.  W.  Richardson,  we  know  the  signs 
and  symptoms  and  can  give  a  dull  catalogue  of  predisposing 
causes,  but  of  the  intimate  cause  we  know  nothing,  and  can 
only  formulate  our  knowledge  in  general  statements,  such  as 
have  been  given  in  the  lecture  upon  retiology. 

The  seat  of  the  pain  is  undoubtedly  in  the  heart  itself. 
The  irradiation  is  a  remarkable  phenomenon  to  which  we 
have  no  other  exact  counterpart  in  visceral  disease — none, 
at  any  rate,  which  is  so  pronounced  a  feature.  Anstie,  Allen 
Sturge,  and  others  have  suggested  the  possibility  of  a  central 
origin  of  the  whole  trouble;  and  I  would  here  remind  you 
of  the  interesting  observation  of  Eichhorst  that  atrophy  of 
the  muscles  of  the  ulnar  side  of  the  left  hand  may  follow  re- 
peated attacks,  which  would  suggest  central  changes  in  the 
spinal  cord.  Which  set  of  nerves  in  the  heart  is  chiefly  in- 
volved, and  what  part  the  intrinsic  ganglia  play,  we  do  not 
know.  It  has  been  suggested  by  Sansom  that  the  pain  is  due 
to  involvement  of  the  sympathetic  fibres,  the  feeling  of  im- 
pending death  to  the  influence  of  the  vagi;  which  recalls  to 
mind  Laennec's  opinion  that  when  the  pain  was  in  the  heart 
and  lungs  the  vagi  were  affected,  and,  when  there  was  simply 
a  sense  of  stricture  of  the  heart  without  difiiculty  of  breath- 
ing, the  grand  sympathetic  was  involved.  Four  possible  ex- 
planations of  the  pain  may  be  mentioned: 

(a)  Cramp  of  the  Heart  Muscle. — In  discussing  the  state 
of  the  heart  during  an  attack  I  have  spoken  of  this  view,  which 
has  much  in  its  favor,  particularly  in  cases  with  anaemic  in- 
farct, but  it  seems  scarcely  applicable  to  all — for  instance,  to 
9 


i 


122 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


1 

\  :|fi 

the  pases  witli  frccjucntly  recurring  attacks,  in  which  one  can 
not  j)ossibly  suppose  infarcts  to  be  present,  though  the  sears, 
of  course,  persist.  The  anah*^}'  with  painful  spasm  in  other 
hollow  organs,  usually  very  insensitive,  is  also  suggestive. 
That  llebenlen  and  Latham — still  masters  in  Israel — stand 
sponsors  for  this  view,  and  that  so  acute  a  modern  observer 
as  liosenbach,  should  conclude  that  the  pain  is  duo  to 
"  changes  in  the  form  of  muscular  contraction,"  conmicnd  it 
strongly  to  our  consideration. 

{b)  Distention  and  Stretching  of  the  Cardiac  Walls. — 
Traube  held  *  that  the  symptom-complex  of  angina  pectoris 
resulted  from  a  rapidly  increasing  distention  of  the  walls  of 
the  ventricle,  which,  in  consequence  of  defective  nutrition, 
were  more  yielding.  When,  owing  to  increased  i)ressure  in 
the  aortic  system,  this  distention  became  excessive,  the  nerve 
elements  in  the  heart  wall  became  stretched  and  bruised, 
causing  the  pain.  You  will  find  a  very  careful  elaboration  of 
this  theory  by  Lauder  Brunton  in  the  Practitioner^  vol.  xlviii. 
A  paragraph  in  a  lecture  by  T.  K.  Chambers  also  suggests 
this  idea:  "The  pain  has  the  same  tearing  and  paroxysmal 
character  that  you  find  accompanying  the  distention  of  hollow 
fibrous  organs,  usually  insensitive,  such  as  the  stomach,  the 
ci)ion,  and  the  bladder.  The  pain  is  of  the  same  nature  as 
that  felt  in  overstrained  tendons  or  muscles  wearied  out  by 
sustained  effort;  it  appears  associated  with  the  stretching  of 
usually  insensitive  fibres,  and  is  sometimes  the  most  dreadful 
agony  the  body  can  bear,  as  the  inventors  of  racks  and  other 
instruments  of  torture  well  knew."  f  Of  course,  this  is  a 
possible  explanation,  but  it  raises  a  problem  insoluble  as  the 
original  one — why,  if  extreme  dilatation  is  a  cause,  angina 
does  not  occur  more  often.    There  must  be  surely  some  addi- 

*  Oesammelte  Beitrdge,  Bd.  iii,  p.  183. 

f  Lectures,  chiefly  Clinical,  fourth  edition,  p.  315. 


SEAT  AND  CAUSE  OP  THE  PAIN. 


123 


tionul  factor,  or  uttutfks  would  be  of  everyday  ocourrciu'o. 
1'lie  relation  of  augeiospaam  to  the  attacks  will  be  discussed 
later. 

((•)  That  the  Pain  in  in  the  Arteries. — Allan  Burns  spoke 
of  the  pain  followinjij  the  tying  of  an  artery  and  the  applica- 
tion of  a  tourni([Ut>t.  Sensory  nerve  endings  have  been  dem- 
onstrated in  the  arterial  walls,  and  it  has  been  suggested  fre- 
quently, in  recent  discussions  on  angina  pectoris,  that  the 
main  element  of  the  attack  may  be  vessel j)ainj  due  to  either 
angeiospasm  or  thrombosis.  There  may  be — there  is  not  al- 
ways— great  pain  in  the  blocking  of  a  large  vessel,  artery,  or 
vein  by  a  thrombus  or  embolus.  The  name  phlegmasia  alba 
doleiis  emphasizes  a  prominent  character  in  th'»  plugging  of 
the  femoral  vein,  and,  as  I  have  just  said,  the  pain  after  liga- 
tion of  the  femoral  or  the  api)lication  of  the  tourniquet  is 
often  very  intense.  Nothnagel  refers  also  to  the  pain  in  the 
head  in  blocking  of  large  cerebral  vessels.  It  is  not  unrea- 
sonable to  suppose  that  pain  of  the  same  nature  may  occur 
in  blocking  of  the  coronary  arteries,  though  I  do  not  call  to 
mind  the  existence  of  special  pain  in  embolism  or  thrombosis 
of  arteries  of  the  size  of  the  coronary  vessels  in  other  organs. 
Moreover,  as  I  have  already  said,  we  can  not  suppose  that  in 
each  attack  a  thrombus  develops.  Angeiospasm  is  a  much 
more  likely  cause  of  the  pain,  and  it  may  be  associated  in 
gome  cases  with  blocking  of  a  vessel.  There  are  the  analogous 
conditions  of  migraine  with  its  vascular  spasm  and  intense 
pain,  and  the  vascular  changes  with  pain  in  Raynaud's  dis- 
ease. Balfour  has  an  interesting  paragraph  upon  this  ques- 
tion of  pain  in  the  arteries: 

"  That  ischffimia  docs  give  rise  to  pain,  even  of  the  most 
atrocious  character,  is  sufficiently  attested  by  the  agony  that 
attends  compression  of  an  artery  for  aneurysm,  especially  at 
the  moment  the  vessel  becomes  completely  occluded;  the 


^,?V:.:':'' 


\i 


m' 


124 


ANGINA  PECTORIS  AND  ALLIED  STATES 


pains,  arising  from  a  similar  cause,  tliat  precede  tlie  appear- 
ance of  gangrenous  patches  in  a  limb  affected  with  senile  gan- 
grene; and  those  which  precede,  accompany,  and  follow  at- 
tacks of  local  asphyxia  (Raynaud's  disease).  There  is  every 
reason  to  suppose  that  the  arterial  spasm,  which  is  so  evidently 
the  cause  of  local  asphyxia,  and  which  takes  so  prominent  a 
share  in  the  production  of  an  attack  of  angina  vasomotoria, 
occasionally  invades  the  heart,  either  as  part  of  a  general  con- 
dition or,  it  may  be,  as  a  distinctly  local  affection,  and  that 
this  is  a  very  possible  cause  of  those  anginal  attacks  where 
no  other  seems  obvious  "  {The  Senile  Heart). 

{d)  That  the  Pain  is  a  Neuralgia,  either  Functional  or  due 
to  a  Neuritis. — This  most  widely  held  view  regards  angina 
pectoris  as  a  form  of  neuralgia  or  neuritis  affecting  the  nerves 
of  the  heart.  Iluchard  mentions  twenty-two  modifications 
of  this  theory,  which  dates  from  the  early  part  of  the  century, 
when,  in  1808,  Baumes  ranked  the  disease  as  a  retrosternal 
neuralgia  (sternalgia).  Laennec  gave  it  his  strong  support 
and  held  that  either  the  pneumogastric  or  sympathetic  divi- 
sion of  the  cardiac  nerves  might  be  implicated,  and  with 
either  of  them  the  brachial  plexus.  Corrigan,  Romberg, 
Bamberger,  and  others  held  the  same  opinion.  Then  in  18G3 
came  the  observations  of  Lancercaux  on  changes  in  the  car- 
diac nerves  and  ganglia,  which  were  confirmed  by  Peter  and 
others.  Iluchard  states  (second  edition,  1803)  that  there  were 
onlv  twelve  observations  on  neuritis  of  the  cardiac  nerves, 
of  which  six  were  associated  with  disease  of  the  coronary 
arteries.  IMore  recent  literature,  so  far  as  I  know,  does  not 
furnish  additional  cases,  and  the  whole  quesiion  of  minute  his- 
tological changes  in  the  sympathetic  nerves  and  ganglia  in 
various  disorders  must  be  reviewed  with  the  help  of  the  new 
technique. 

Against  this  theory  may  be  urged  the  common  observa- 


VASO-MOTOR  CHANGES  IN  ANGINA. 


125 


tion  that  the  cardiac  nerves  may  be  seriously  implicated  iu 
aneurysm,  in  mediastinal  tumors,  in  adherent  pericardium, 
and  in  the  exudate  of  acute  pericarditis  without  causing  the 
slightest  pain. 

Again,  in  the  attack  of  angina,  though  the  pain  is  a  promi- 
nent feature,  it  is  a  part,  and  in  a  severe  attack  the  minor 
part,  of  the  paroxysm.  The  angor  animi  is  very  unlike 
anything  met  with  in  neuralgic  affections.  Moreover,  the 
mode  of  onset  following  exertion  or  emotion  is  not  a  feature 
of  neuralgia,  and  this  view  affords  no  solution  of  the  sudden 
death  which  sometimes  follows.  In  its  paroxysmal  charac- 
ter and  radiation,  and  in  its  intensity,  the  pain  is  much  more 
like  that  of  biliary  and  renal  colic;  with  the  latter,  indeed, 
I  have  heard  a  patient  who  had  experienced  both  compare  it. 

Of  course,  the  pain  suffered  in  an  attack  of  angina  is  a 
manifestation  of  disturbed  function  of  the  nerves.  Such  dis- 
turbance, when  associated  with  pain,  may  be  called  neuralgic, 
but  it  is  evident,  from  what  has  been  stated,  that  there  is 
something  in  addition,  which  puts  the  attack  out  of  the  cate- 
gory of  ordinary  painful  affections  of  the  nerves.  There  are 
many  conditions  about  the  heart  in  which  the  nerves  are  di- 
rectly implicated  with  which  neuralgia  occurs.  I  have  already 
told  you  that  there  is  no  constancy  in  this,  and  there  may  be 
old  pericardial  adhesions,  fresh  epicarditis  with  direct  involve- 
ment of  the  superficial  nerves,  or  there  may  be  sclerosis  of 
the  root  of  the  aorta,  aneurysm  or  tumor  with  pressure  on 
the  pneumogastric,  without  any  pain  whatever.  But  again, 
in  all  of  these  conditions  there  may  be  recurring  attacks  of 
pain  about  the  heart,  sometimes  of  great  intensity,  and  even 
simulating  that  of  true  angina. 

III.  Vaso-motor  Changes  in  Angina. — In  Lecture  III  I 
mentioned  the  striking  vaso-motor  phenomena  of  the  attack 
— the  pallor,  the  coldness,  and  the  sweating — and  in  the  last 


I 


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1- 

*1 

1 
1 

126 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


lecture  I  spoke  of  a  special  type  of  pseudo-angina  in  which 
these  features  dominated  the  scene.  They  play  a  conspicuous 
role  both  in  the  functional  and  organic  forms.  Naturally, 
one  approaches  a  vaso-motor  problem  with  a  good  deal  of 
caution,  since  it  lends  itself  with  singular  aptness  to  theo- 
retical vagaries  and  to  all  kinds  of  speculation.  It  is  well  to 
remember  that,  as  Foster  remarks,  the  vaso-motor  nerves  are 
servants,  not  masters,  in  the  matter  of  regulating  the  calibre 
of  vessels  and  altering  the  blood  pressure. 

I  have  already  spoken  of  -ho  <k'  of  the  arteries  during 
the  paroxysm,  and  have  give:  a  .jummary  of  my  personal 
experience  on  this  moot  question.  The  general  opinion  is 
that  in  true  angina  there  is  an  early  angeiospasm  with  gi'eat 
increase  in  the  blood  pressure,  Sphygmographic  tracings 
during  the  attack  have  not  often  been  made.  Lauder  Brun- 
ton's  observation  is  particularly  interesting,  and  I  show  you 
here  the  tracings  which  he  gives,  taken  from  the  radial  pulse 
before  and  during  an  attack.  It  can  not  be  doubted,  I  think, 
that  in  many  cases  an  important  factor  is,  as  Mitchell  Bruce 
expresses  it,  too  much  pressure  ahead  of  fho  driving  power; 
but  this  widespread  peripheral  spasm  is  ;;•  <1  ^b]y  a  secondary 
phenomenon,  excited  reflexly  through  ii  ^i.  r-e'-  on  the  vaso- 
motor centre  coming  from  the  heart  itself  or  t-'.iv  other  parts. 
Morison,  of  whose  paper  in  volume  iii  of  the  Edinhnt^gh  Hos- 
pital Reports  I  have  already  spoken,  gives  the  notes  of  a  pa- 
tient with  aortic  insufficiency,  in  whom  during  an  attack  the 
pulse  tension  was  low,  and  he  thinks  that  even  in  the  organic 
form  there  may  be  considerable  variations,  more  especially  in 
the  eases  with  or  without  insufficiency  ,  \\\o  aortic  valve.  It 
may  be  questioned,  indeed,  whether  the  na'j'i.ig  in  Brunton's 
ease  really  represents  a  r^^at  increase  in  the  tension,  or  wheth- 
er it  does  not  mean  thai  tbe  left  ventricle  was  in  a  condition  of 
feebleness  or  dilatation,  m.\  the  pulse  tension  extrcmelv  low. 


-L. 


VASO-MOTOR  CHANGES  IN  ANGINA. 


127 


I  show  you  here  by  way  of  contrast  the  tracings  given  by 
Iluchard,  in  which,  as  you  notice,  the  one  in  the  interval  be- 
tween the  attack  with  the  low  tension  resembles  very  much 
that  of  Brunton's  during  the  attack  with  supposed  high  ten- 
sion. 

A  majority  of  patients  with  true  angina  have  reached  an 
age  in  which  naturally  the  blood  tension  is  increased,  and  in 
almost  every  instance  the  exciting  causes  of  the  paroxysm  are 
those  which  raise  the  arterial  pressure — mental  emotion,  mus- 
cular exertion,  cold  to  the  periphery,  and  dilatation  of  the 
stomach.  You  will  find  in  Brunton's  paper  an  admirable 
discussion  of  the  importance  of  these  factors  in  raising  the 
blood  pressure,  and  in  bringing  about  th''  anginal  paroxysm. 

Favoring,  too,  this  view  of  widespread  angeiospasra  is  the 
circumstance  that  in  certain  cases  of  Raynaud's  disease  an- 
gina pectoris  of  a  very  severe  type  has  occurred,  and  has  even 
proved  fatal.  The  most  interesting  case  of  this  kind  in  the 
literature  is  reported  by  Richard  Cleeman.*  A  man,  aged 
sixty-two  years,  had  from  his  fiftieth  year  severe  attacks  of 
Raynaud's  disease,  chiefly  in  the  hands,  which  occurred  usu- 
ally in  the  winter  season.  One  day  he  had  an  attack  of  ago- 
nizing substernal  pain  lasting  for  two  hours,  and  of  such  in- 
tensity that  he  was  greatly  prostrated.  The  pains  radiated 
down  both  arms.  During  a  period  immediately  preceding  this 
he  had  had  very  pronounced  attacks  of  local  asphyxia  and 
local  syncope,  chiefly  in  the  hands.  A  week  later  he  was 
found  dead  in  bed. 

The  association  of  migraine  with  angina  pectoris,  particu- 
larly the  vaso-motor  form,  has  been  long  recognized,  and  in 
two  cases  in  my  series  the  subjects  had  been  great  sufferers 
with  this  disease. 


*  Transaction  of  the  College  of  Physicians,  Philadelphia,  189'^. 


fr' 


128 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


J;  I 


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There  are  two  possible  explanations  of  tlie  vaso-motor  phe- 
nomena of  angina  pectoris.  In  the  first  place  a  widespread 
vaso-motor  spasm,  excited  reflexly  by  cold,  by  emotion,  by 
flatulence,  etc.,  throws  a  great  strain  upon  the  left  ventilcle 
with,  as  Traube  thought,  distention,  stretching,  and  conse- 
quent pain.  Of  course,  in  this  widespread  angeiospasm  the 
coronary  vessels  themselves  may  participate,  and  it  is  not  at 
all  improbable  that  in  the  hysterical  and  vaso-motor  varieties 
of  angina  the  entire  symptom-complex  may  be  vaso-motor. 
The  possibility  of  a  local  (coronary)  angeiospasm  may  be 
admitted  in  the  toxic  cases  and  in  organic  disease  of  the  coro- 
nary arteries.  On  the  other  hand,  the  widespread  constrictor 
influence  in  the  systemic  arteries  in  an  attack  of  true  angina 
may  itself  be  a  vaso-motor  reflex.  Ilcgar  showed  experimen- 
tally that  a  great  increase  in  the  general  blood  pressure  could 
be  excited  reflcxly  on  the  injection  of  nitrate  of  silver  into  the 
peripheral  artery  of  a  rabbit.  In  the  same  way  the  pallor, 
coldness,  sweating,  and  general  vaso-contrictor  influences  in 
true  angina  may  be  excited  reflcxly  by  afferent  impulses  from 
the  coronary  vessels  themselves. 

Relations  of  Pseudo  to  True  Axgixa. — One  other  mat- 
ter remains  for  brief  comment.  AVhat  relation  do  the  phe- 
nomena of  spurious  angina  bear  to  those  of  the  organic  affec- 
tion? Iliichard  insists  upon  the  absolute  separation  of  the 
organic  form  associated  with  coronary-artery  disease  from  the 
various  other  types  of  cardiac  pain.  He  says:  "7Z  ?i'y  a  pas 
plusleurs  angines  de  jpoitrlne  ;  il  rCy  en  a  qu\tne  seiile^  Van- 
gine  coronarienne.''^  According  to  him  the  pseudo-anginas 
are  neuralgias  of  the  cardiac  plexus  due  to  various  causes,  or 
a  vaso-motor  neurosis.  It  must  be  acknowledged  that  the  at- 
tacks of  vaso-motor  angina  and  of  the  form  seen  in  nervous 
and  hysterical  women  have  many  of  the  cliaracters  of  a  parox- 
ysmal neurosis,  resembling  indeed  in  certain  particulars  mi- 


_U 


RELATIONS  OF  PSEUDO  TO  TRUE  ANGINA. 


129 


)lie- 
ead 

by 


graine.  Closely  allied  as  no  doubt  many  of  the  underlying 
conditions  are,  and  simulating  often  the  features  of  the  genu- 
ine attack,  I  fully  concur  with  Iluchard  and  others  who  sepa- 
rate the  functional  from  the  organic  form;  and,  while  the 
former  come  very  projierly  in  the  category  of  paroxysmal  neu- 
roses, the  true  angina  presents  features  entirely  unlike  a  neu- 
ralgia. The  chief  objections  have  been  well  and  clearly  put 
by  Fagge:  "  But  for  a  neuralgia  to  prove  habitually  fatal  is 
without  precedent.  JMoreover,  angina  pectoris  differs  from  all 
neuroses  in  being  generally,  if  not  always,  associated  with  the 
existence  of  organic  lesions  in  the  heart  or  in  the  gTcat  vessels, 
although  it  would  seem  that  no  one  lesion  is  constantly  pres- 
ent; this,  at  any  rate,  is  true  of  the  cases  that  destroy  life. 
Thirdly,  it  is  unlike  a  neuralgia  to  attack,  as  angina  does  by 
a  large  preponderance,  more  males  than  females — as  many 
as  ten  men  to  one  women." 

In  the  neurotic  form  the  fundamental  error  appears  to 
be  a  vaso-motor  instability,  for  which  S.  Solis-Cohen  has  sug- 
gested the  name  vaso-motor  ataxia,  a  term  which  really  defines 
the  condition,  a  loss  of  the  power  nicely  to  balance  the  distri- 
bution of  blood  in  the  vascular  territories.  In  the  organic 
form  not  only  is  the  question  much  more  complicated,  but 
there  are  features  quite  inexplicable  in  the  present  state  of 
our  knowledge — notably  the  haphazard  incidence  in  anatomi- 
cal conditions  apparently  identical,  the  causation  of  the  pain, 
and  the  relation  of  the  blood  pressure,  cardiac,  coronary,  and 
systemic,  to  the  phenomena  of  the  attack. 


AVero  the  problems  of  blood  pressure  solved,  angina  pec- 
toris would  be  an  open  book  to  us;  but  in  spite  of  the  unceas- 
ing work  of  the  past  thirty  years  much  obscurity  remains,  with 
not  a  little  dissonance  and  discord.  The  trained  student 
among  you  who  wishes  to  get  upon  a  working  basis  should 


I 

IJ! 

lit 


130 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


study  the  articles  of  Porter  referred  to  in  Lecture  I,  the  im- 
portant monograph  of  Roy  and  Adami,*  the  Heart  Studies  f 
of  Ewart,  von  Basch's  works  and  his  recent  brochure  on  Ge- 
fclssstarre  (Angiorhigosis)  :j: — these,  with  Tigerstedt  *  as  a 
sort  of  Baedeker,  will  promote  his  enlightenment.  The  less 
ambitious  will  be  content  with  the  lucid  account  in  Stewart's 
Physiology ,  facile  princeps  among  manuals  on  the  subject. 

*  Philosophical  Transactions,  1892. 
f  London,  1894. 

j  Vienna,  1896. 

*  Lehrbuch  der  Physiologie  des  Kreislaufes,  Leipsic,  1893. 


IS  - 

i 

1 1 

i 

m- 

}e- 
a 

CSS 

•t's 


LECTURE  VII. 


DIAGNOSIS,    PROGNOSIS,    AND   TKEATMENT    OF    ANGINA. 

Anomalous  cases  of  heart  pain. — Elements  in  the  diagnosis  of  true  angina. — 
Ditrerentiation  of  true  and  pseudo  an^.  ina. — Prognosis. — Treatment  of 
angina  pectoris  vera. — Treatment  of  false  angina. — Conclusion. 

Diagnosis. — One  must  be  a  professional  ITlysses  in  craft 
and  wisdom  not  sometimes  to  err  in  estimating  the  ri.)tiire  of 
an  attack  of  severe  heart  pain.  There  is  no  group  of  cases  so 
calculated  to  keep  one  in  a  condition  of  wholesome  humility. 
AVhen  you  jostle  against  a  hale,  vigorous  specimen  of  human- 
ity, who  claps  you  on  the  back  and  says,  "  The  deuce  take 
you  doctors!  I  have  scarcely  yet  got  over  my  fright,"  you 
would  like  to  forget  that  five  years  before  you  had  almost 
signed  his  death  Avarrant  in  a  very  positive  diagnosis  of  angina 
pectoris  vera.  On  the  other  hand,  Mr.  X.  has  left  you  with 
the  full  assurance  that  his  cardiac  pains  are  due  to  overwork 
or  tobacco,  and  vou  have  comforted  his  wife  and  lifted  a 
weight  of  sorrow  from  both  by  your  most  favorable  prognosis. 
With  what  sort  of  appetite  can  you  eat  your  breakfast  when, 
a  week  later,  you  read  in  the  morning  paper  the  announce- 
ment of  his  sudden  death  in  the  railway  station?  Or  take 
another  aspect — poor  Mrs.  Doe  has  gone  softly  all  these  years 
in  the  bitterness  of  her  soul  since  you  took  that  grave  view 
of  her  vaso-motor  or  hysterical  angina! 

As  a  rule  vou  will  have  little  or  no  doubt  as  to  the  exist- 

ence  of  angina.    The  chief  difficulty  is  in  deciding  upon  the 

131 


I 

i  : 


I 


.  V 


ii 


132 


AXGINA  PECTORIS  AND  ALLIED  STATES. 


functional  or  organic  nature  of  the  trouble.  There  are,  how- 
ever, extraordinary  cases  of  recurring  pain  about  the  heart, 
of  terrible  severity,  the  nature  of  which  may  be  very  obscure. 
The  following  is  one  of  the  most  remarkable  cases  of  this 
kind  which  I  have  met: 

J.  H.  McC,  aged  forty-nine  years,  seen  April  28,  1887,  com- 
plaining of  attacks  of  terrible  substernal  i)ain.  lie  was  a  largo, 
active  man,  weighing  a  hundred  and  ninoty-iivo  pounds.  With 
the  exception  of  a  chancre  at  his  llftccntli  year,  whieh  was  fol- 
lowed by  an  ulcer  on  the  leg  ciglit  months  afterward,  and 
typhoid  fever  three  years  ago,  his  general  health  has  been  good. 

Twelve  years  ago  (1875)  he  consulted  Dr.  Weir  Mitchell  for 
the  following  symptoms:  Every  morning,  about  one  o'clock,  he 
was  aroused  from  sleep  with  severe  j)ains  in  the  lower  part  of  the 
chest,  beneath  the  sternum.  At  first  the  attacks  occurred 
every  night,  and  then  at  intervals  of  four  or  five  days.  The  pain 
was  not  like  a  crauip  or  a  spasm,  but  dull  and  severe,  intense 
enough  to  make  him  get  up  and  walk  the  room.  For  nearly 
ten  years  the  attacks  made  his  life  a  burden.  Thev  ceased 
abruptly  in  1885,  since  which  date  he  has  been  quite  well  until 
March  28th  of  this  year.  He  now  has  the  attack  every  day  about 
1  A.  M.  lie  goes  to  bed  at  ten  o'clock  and  falls  to  sleep  com- 
fortably. Usually  about  1  a.  m.,  sometimes  at  three  or  four 
o'clock,  he  is  aroused  by  a  fixed  pain  beneath  the  sternum  be- 
tween the  fourth  and  fifth  costal  cartilages.  It  is  never  trans- 
mitted down  the  arilT;  he  is  never  doid}led  up  with  it,  no-  does 
he  turn  pale  or  sweat.  lie  occasionally  belches  wind  during 
the  attack.  The  ])ain  at  times  is  so  severe  that  he  has  to  talvo 
an  anaesthetic.  Thus  on  the  29th  he  awoke  at  3.30  a.  m.  in 
terrible  agony,  and  bad  to  take  ether.  lie  slept  until  after  five 
o'clock,  when  the  pain  again  came  on  and  persisted  until  noon. 
He  says  he  has  noticed  that  it  is  often  worse  after  the  rest  of  Sun- 
day. The  examination  was  entirely  negative.  The  arteries  were 
not  stiif ;  the  heart's  action  was  regular;  the  aortic  second  sound 
was  not  accentuated.  He  winced  a  little  on  deep  pressure  just 
above  the  ensiform  cartilage.    The  urine  was  normal. 

He  had  taken  iodide  of  potassium  previously  without,  he 


DIAGNOSIS  OF  ANGINA  PECTORIS. 


133 


o\v 
art 


lire, 
this 


om- 

rtro 


tlioufjlit,  any  benefit.  Consitlerir.g,  liowever,  the  history  of 
syphilis,  I  insisted  that  he  shoulr  take  it  again.  I  heard  from 
him  on  several  occasions  for  a  year  or  so,  and  there  was  not  very 
much  cliange  in  his  condition.    I  have  since  lost  track  of  him. 

A  somewhat  similar  case  to  this  is  reported  by  Dr.  Ran- 
dall, of  Decatur,  in  the  Medical  Neios  for  ]!i[arch  11,  1803. 
The  patient  was  a  healthy  man  who  had  remarkable  seizures 
of  agonizing  pain  in  an  area  twelve  inches  in  diameter  over 
the  heart,  which  recurred  nightly  from  August  1st  to  Decem- 
ber lOth  unless  he  remained  awake  and  out  of  bed.  The  pa- 
tient was  a  self-possessed,  unimaginative  man,  and  had  never 
had  similar  attacks.  The  pain  was  sometimes  greatest  in  the 
epigastrium,  sometimes  in  the  prsecordium,  and  with  it  there 
were  tingling  and  numbness  in  the  arms,  and  a  sense  of  suffo- 
cation. There  was  no  dyspnoea  or  asthmatic  breathing.  The 
patient  could  avert  the  attack  every  night  by  vigilance.  It  is 
difficult  to  decide  upon  the  nature  of  such  cases. 

The  important  elements  in  diagnosis  are  the  sex,  the  pres- 
ence of  cardio-vascular  disease,  and  the  phenomena  of  the 
attack. 

Upon  the  infrequency  of  true  angina  in  women  I  have 
already  dwelt,  and  you  must  be  cautious  even  when  the  gen- 
eral features  of  the  case  are  most  suggestive.  Such  an  in- 
stance, for  example,  as  the  following  should  not  deceive  you: 


II    I 


Mrs.  R.,  aged  forty-two  years,  seen  October  25,  1894.  She 
has  always  been  a  healthy  woman,  but  has  had  much  trouble 
and  worry.  Her  husband  had  attacks  of  angina  pectoris,  and 
died  a  year  ago  of  heart  disease.  Her  mother  died  in  an  attack 
of  angina  pectoris  three  years  ago.  For  nearly  a  year  she  had 
been  unable  to  rest  comfortably  on  her  left  side,  and  had  been 
much  troubled  with  pains  about  the  heart,  which  were  some- 
times of  great  severity,  and  were  then  accompanied  by  a  feel- 
ing of  numbness  in  the  left  arm  extending  to  the  fingers. 


Ill 

ill'  ■ 
% 

■  'ri 


I  ( 


if 


134 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


Neither  diet  nor  exercise  seemed  to  ;;iake  any  difTerence,  and 
she  never  had  dyspniea.  Sonieiinies  tlie  wliole  of  the  left  side, 
inehidin};  the  neck,  would  feel  stiil'  and  sore.  Thoujjh  she  had 
heen  free  for  a  few  days  from  the  sensations  of  i)ain,  she  had  not 
within  the  past  year  had  a  week  of  com[)lete  intermission.  She 
had  evidently  worried  very  nuieli  ahout  it,  and  dreaded  con- 
sultin^f  a  physician,  lest  she  should  he  told  she  had  the  disease 
of  which  her  mother  and  hushand  had  died. 

The  patient  was  a  healthy  looking  woman.  The  pulse  was 
quiet,  without  increase  in  the  tension,  and  the  arteries  were  not 
stiff.  There  were  no  signs  of  hyj)ertrophy  or  dilatation  of  the 
heart;  the  sounds  were  normal.  The  urine  had  a  specific  gravity 
of  1.018,  and  was  free  from  alhumin  and  tuhe  casts.  I  have 
seen  this  patient  on  several  occasions  during  the  past  two  years, 
and  her  condition  has  improved  verj'  much. 


f!': 


m. 


V 


% 


\ 


There  are  cases,  too,  in  wliieli  hysterical  angina  oecnrs  in 
women  with  aortic  valve  disease.  The  only  instance  of  the 
kind  which  has  come  under  my  notice  is  the  following: 

Mrs.  K.,  aged  thirty-eight  years,  seen  Fehruary  24,  1890. 
The  patient  was  an  unusually  bright,  able  woman,  who  had  for 
several  vears  lived  under  a  }rious  mental  strain.  She  had  severe 
rheumatism  as  a  child,  and  she  had  been  told  by  several  })hysi- 
cians — among  others  the  late  Dr.  Austin  Flint  and  Dr.  Da  Costa 
— that  she  had  heart  disease.  The  first  serious  attack  of  ])ain 
about  her  heart  was  two  years  ago  at  a  hotel,  when  she  fainted. 
During  the  past  three  months  she  had  had  eight  or  ten  attacks. 
They  usually  came  on  when  she  was  worried  or  very  anxious. 
She  got  cold;  the  pains  began  just  under  the  left  breast  and  shot 
into  the  arm  and  up  the  neck.  During  the  attacks  her  physician 
said  she  had  often  been  quite  hysterical,  tossing  herself  about, 
and  talking  in  a  very  incoherent  way.  The  apex  beat  of  the 
heart  was  a  little  outside  the  normal  position;  the  aortic  second 
sound  was  intensified,  and  at  midsternimi,  opposite  the  third 
costal  cartilage  and  along  the  left  border  of  the  sternum,  there 
was  a  soft  diastolic  murmur.  The  pulse  was  regular,  a  little 
jerky;   the  vessel  wall  was  a  little  firmer  than  normal.    When 


DIAGNOSIS  OF  ANGINA  PECTORIS. 


135 


and 

I  side, 

had 

not 

She 

con- 

Isease 

was 

not 

the 

avity 

have 

■ears, 


I  ?aw  her  she  was  having  pretty  frequent  attaeks,  and  was  very 
nervous  and  hysterical.  After  removal  from  her  home  sur- 
roundings, with  rest  and  quiet,  and  a  course  of  tonics,  she  im- 
])roved  very  greatly.  After  my  examination  I  made  the  follow- 
ing note:  "  Do  the  attaeks  represent  true  or  hysterical  angina? 
'J'hat  there  is  a  strong  neurotic  element  is  undouhted,  but  the 
])resence  of  aortic  insufliciency,  a  condition  which  had  been 
recognized  by  several  physicians  some  years  ago,  makes  the  diag- 
nosis a  little  dubious."  I  have  seen  the  patient  at  intervals 
during  the  jiast  six  years,  and  she  has  had  no  recurrences  of  the 
attacks,  and  has  been  in  excellent  health. 

The  extreme  rarity  of  true  angina  in  women  must  always 
bo  borne  in  mind,  and  also  the  infrecpicncy  of  its  association, 
as  notc(l  in  Lecture  II,  with  mitral-valve  disease.  Flushes, 
I)artrsthesia^,  and  various  nervous  or  hysterical  nuinifesta- 
tions,  and  particularly  the  vaso-dilator  type  of  phenomena, 
suggest  strongly  pseudo-angina,  even  though  a  loiul  mitral 
muniiur  be  ])resent.  I  saw  with  Dr.  Clark,  of  Kingston, 
Ontario,  a  very  puzzling  case  of  this  kind,  the  notes  of  which 
I  have  unfortunately  mislaid. 

In  men,  while  true  angina  may  coexist  with  apparently 
normal  cardio-vascnlar  condition,  in  a  very  large  proportion 
of  all  cases  there  are  signs  of  greatly  heightened  blood  pres- 
sure, or  of  sclerosis  of  tiie  arteries,  with  a  ringing  metallic 
aortic  second  sound;  sometimes  only  the  signs  of  a  weak 
heart.  In  men  under  the  age  of  forty  the  existence  of  syphilis 
should  be  suspected,  iis  a  by  no  means  inconsiderable  number 
of  cases  result  from  an  aortitis,  causing  great  swelling  of  the 
intima  and  narrowing  of  the  orifices  of  the  coronaries. 

In  men,  too,  the  question  of  tobacco  has  always  to  be  con- 
sidered, as  recurring  paroxysms  of  really  maximum  intensity 
may  be  due  to  persistent  smoking  or  chewing. 

In  determining  between  a  true  and  a  false  angina,  the 
phenomena  of  the  attack  offer  must  valuable  differential  cri- 


if 


w    » 


il 


136 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


If' 


tcvin.  Tlio  c'liarac'tcr  of  the  pain  in  ps(Mi(lo-anp;inn,  wliilo  it 
may  be  very  severe,  rarely  has  the  agonizing  (puility  of  true 
angina,  and  is  seldom,  if  ever,  associated  with  the  sensation 
of  imjtending  death.  Patients  more  often  ('omi)lain  of  a  sense 
of  fullness  and  distention  in  the  lieart.  The  seat  of  the  ])ain 
nniy  be  in  both  identical,  and  I  do  not  think  that  much  stress 
can  be  laid  on  the  point  that  in  i)seudo-angina  the  maximum 
pain  is  more  over  the  heart  aiul  toward  its  apex,  while  in  the 
organic  disease  the  chief  seat  of  the  pain  is  toward  the  base 
of  the  heart  and  over  the  aorta.  You  must  remend)er  that  in 
true  angina  the  seat  of  the  pain  nuiy  be  entirely  away  from  the 
chest,  and  may  be,  as  in  Lord  Clarendon's  father,  at  the  inner 
aspect  of  the  arm,  or  about  the  wrist,  or  in  rare  instances  con- 
fined to  the  side  of  the  neck,  or  even  to  one  testis.  While  in 
both  forms  the  pain  may  radiat  the  side  of  the  neck  and 
to  tlie  left  arm,  in  psendo-angi  .0  associated  nervous  sen- 
sations are  apt  to  be  much  more  widespread.  There  may  be 
numbness  and  tingling  in  both  extremities,  or  prior  to  the 
onset  there  may  be  a  feeling  of  pins  and  needles  in  the  hands 
and  feet.  The  vaso-motor  phenomena  are  apt  to  be  much 
more  prononnced  in  psendo-angina.  The  attack  may  bo  pre- 
ceded by  flushes,  by  a  sensation  of  great  oppression  in  the 
back  of  the  neck  or  head,  and  then  before  the  onset  of  the 
cardiac  pain,  not  with  it  or  following  it,  there  is  coldness  of 
the  extremities  and  sometimes  a  pronounced  tremulousness 
amounting  to  what  is  popularly  called  a  nervous  chill.  Sweat- 
ing, combined  with  the  pallor,  is  not  so  common  in  pseudo- 
angina.  The  paroxysms  of  false  angina  rarely  have  great 
abruptness  of  onset,  but  arc  preceded  by  various  nervous  and 
hysterical  features. 

The  attitude  in  angina  pectoris  vera  is  one  of  its  most 
characteristic  features.  The  patient  rarely  can  stir  from  the 
spot  in  which  he  is  attacked.     In  the  hysterical  and  neuras- 


'II, 


DIAGNOSIS  OF  ANGINA  PECTORIS. 


137 


n 


tlu'iiic'  nngiiia  tluTc  ia  often  groat  jnctitntion,  seldom  iinmo- 
Itility.  The  patient  tosses  about  on  tho  bed  with  noisy  cx- 
eliiinations  of  ])ain,  or  may  walk  the  floor  screaming  loudly. 

Tiic  duration  of  the  attack  in  pseudo-angina  is  usually 
n.oro  prolonged,  lasting  perhaps  an  hour  or  more.  As  I  have 
already  mentioned,  it  oeeasiomdly  happens  that  even  in  tho 
true  angina,  as  in  ^fr.  Sumner's  ease,  tho  patient  is  able  to 
walk  about,  finding  relief  in  moderate  oxcrciso  during  tho 
attack. 

And,  lastly,  among  tho  important  points  of  diagnosis  are 
tho  cir"umstances  which  promote  tho  attacks.  In  true  angina 
the  patient  can  nearly  always  fix  upon  some  provocation,  as 
nuiscular  effort,  mental  irritation,  an  attack  of  indigestion; 
whereas  in  i)seudo-angina  the  attacks  are  much  more  apt  to 
occur  spontaneously,  and  rarely  arc  excited  by  effort. 

It  must  bo  acknowledged  that  the  diagnosis  is  not  always 
so  easy  as  you  might  sui)ose  from  any  glib  sunnnary  of  dif- 
ferential signs;  thus  just  tho  other  day  I  was  consulted  by  a 
practitioner  from  ono  of  the  large  AVostorn  cities,  in  whose 
case  tho  existence  of  certain  well-pronounced  coincident  nerv- 
ous phenomena  secmocl  alone  to  clinch  the  question  of  diag- 
nosis. The  patient  was  aged  about  fifty,  a  strong  man,  of 
strong  stock,  who  had  been  engaged  in  large  general  practice 
for  more  than  twenty-five  years.  He  had  never  had  syphilis, 
and  bad  been  temperate  in  the  use  of  alcohol  and  tobacco; 
somewhat  intemperate  in  coftoe.  He  had  lived  a  life  of  a  good 
deal  of  tension,  but  had  beeii  very  well,  with  the  exception 
of  at  intervals  rheumatic  and  neuralgic  pains.  He  had  never 
had  gout.  Two  years  ago,  after  a  long  and  tiring  drive,  he 
went  out  one  evening  to  make  a  visit,  and  while  at  the  patient's 
door  bad  a  very  severe  attack  of  pain  about  the  apex  of  the 
heart,  which  lasted  for  a  minute  or  two,  and  which  fright- 
ened him  very  much.  The  next  day  at  dinner  he  was  seized 
10 


;' ,! 


Ml 

m 


ill 


1 


138 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


!:■ 


T    i 


I 


.1 


again,  Lnt  the  pain  was  scarcely  so  intense;  it  was  duller  and 
more  boring  in  character,  lie  sniTered  all  night,  and  in  the 
morning  had  to  take  a  hypodermic  injection  of  morpiiine. 
lie  had  no  faintness,  the  circulation  was  not  involved,  and 
there  was  no  sense  of  impending  dissolution.  lie  felt  very 
weak  and  used  up  for  nearly  a  week.  He  had  no  return  what- 
ever of  the  pain  until  last  October.  He  had  been  working 
very  hard,  and  had  lost  a  great  deal  of  rest.  Then  he  had 
the  pains  at  intervals,  while  he  was  driving,  at  the  table,  when 
walking,  or  in  bed.  They  were  never  very  severe,  and  did 
not  interfere  with  his  work.  They  were  chiefly  about  the  apex 
of  the  heart,  not  beneath  the  sternum.  Tliev  radiated  down 
the  arms,  particularly  the  left,  but  he  has  had  pains  in  both 
anns  as  far  as  the  wrists,  with  numbness,  and  on  :;everal  occa- 
sions he  has  had  pain  and  numbness  in  the  left  arm  without 
the  pain  about  the  heart.  These  attacks  persisted  on  and  off 
all  through  the  winter,  until  about  two  months  ago.  lie 
then  had  an  attack  of  influenza  with  fever,  and  since  then  he 
has  had  a  great  deal  of  nervous  palpitation  of  the  heart,  par- 
ticularlv  with  emotion,  or  if  his  stomach  is  full.  He  does  not 
appear  ever  to  have  had  a  severe  agonizing  attack  with  sweat- 
ing and  a  sense  of  impending  dissolution. 

Certainly  in  a  man  of  over  fifty,  though  his  heart  was 
normal,  and  his  arteries  not  specially  sclerotic,  and  the  pulse 
tension  very  little  raised,  such  attacks  wer  •,  to  say  the  least, 
suggestive  of  true  angina.  But  on  goinr,  into  his  case  more 
fully  two  circumstances  developed,  wh'jh  were,  I  think,  of 
much  moment,  indicating  probably  that  he  was  of  a  more 
neurotic  temperament  than  he  was  willing  to  confess.  Be- 
tween three  and  four  years  ago,  when  overworked  and  worried, 
he  had  extraordinary  attacks  of  slight  spasm  of  the  glottis, 
which  would  come  on  while  he  was  taking  food,  or  at  any 
time  if  he  was  very  excited.     It  would  be  relieved  with  a 


PROGNOSIS  (F  ANGINA  PECTORIS. 


139 


deep,  noisy  inspiratl  n  a]  nost  like  childcrowing.  These  at- 
tacks passed  away,  ana  lie  hap  not  had  them  since.  But  last 
sunnner  his  wife  says  that  he  had  the  most  extraordinary 
attacks  of  spasm  of  the  gullet,  recurring  at  every  meal  for 
nearly  six  weeks.  At  the  first  attempt  at  swallowing,  either 
of  liquids  or  of  solids,  there  would  be  a  sudden  interruption, 
which  he  describes  as  a  sort  of  spasm  of  the  gullet,  and  he  had 
to  wait  several  minutes  for  it  to  pass  oif  before  he  could  take 
another  mouthful.  This  patient  Vi^as  very  nervous  and  appre- 
hensive tliat  he  had  true  angina,  and  yet  I  think  the  exist- 
ence of  well-marked  cesophagismus  and  of  laryngeal  spasm 
three  or  four  years  ago  are  circumstances  which  suggest  a 
diagiiosis  of  pseudo-angina. 

Prognosis. — One  of  the  most  distinguishing  features  of 
true  angina  is  a  consciousness  on  the  part  of  the  patient,  in 
his  anguish  of  mind,  that  the  very  citadel  of  life  has  been 
approached.  In  a  severe,  long-continued  paroxysm  all  de- 
sire of  recovery  may  be  absent  in  the  dread  lest  he  should 
have  again  to  endure  tlie  agony.  Subjects  of  the  disease  may 
truly  be  said  to  stand  in  jeopardy  every  hour,  yet  it  is  astonish- 
ing with  what  equanimity  the  affliction  is  endured.  Charles 
Sumner  said :  "  This  treacherous  disease  produces  in  my  mind 
a  positive  uncertainty  when  I  go  out  of  my  house  whether  I 
shall  evor  enter  it  again  a  living  man."  The  duration  of  the 
disorder  is  most  uncertain;  there  are  notable  cases,  such  as 
John  Hunter,  in  which  the  attacks  have  recurred  at  intervals 
for  twentv  or  more  vears. 

Recovery  is  (]uite  possible,  and  there  are  instances  in  which 
the  attacks  disappear  entirely.  In  June  of  last  year,  in  con- 
sultation out  of  town  about  a  ease  of  heart  disease.  Dr. 

mentioned  to  me  his  own  case  as  one  of  exceptional  interest. 
He  was  a  man  of  fifty  years  of  age,  and  had  been  in  very  active 
practice,     ^wenty  years  ago,  he  had  been  for  nearly  a  year 


140 


ANGIXA  PECTORIS  AND  ALLIED  STATES. 


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111 

a  terrible  sufferer  witli  angina.  He  was  under  the  care  of 
the  late  Dr.  Donaldson,  who  regarded  the  attacks  as  genuine, 
as  there  was  also  well-marked  aortic  insufficiency.  The  pa- 
tient has  remained  perfectly  free  for  twenty  years. 

I  saw  in  November,  188G,  with  Dr.  J.  William  White,  a  naval 
officer,  ajjod  forty-six  years,  who  had  had  severe  attacks  of  angina 
associated  with  inniiobiiity  and  a  sense  of  great  aiic/or.  lie  was 
a  powerfully  built  man,  who  had  lived  well  and  had  taken  a 
groat  deal  of  heavy  exercise.  The  pulse  tension  was  increased 
and  the  aortic  second  was  accentuated,  lie  had  been  a  heavy 
smoker,  but  had  not  had  syphilis.  lie  had  kejjt  a  very  accurate 
account  of  the  attacks,  and  he  had  between  October  11,  188G, 
and  August  11,  1887,  two  hundred  and  thirty-nine,  most  of  them 
sligiit,  but  some  of  terrible  severity.  From  the  date  mentioned 
to  the  present  he  has  remained  perfectly  well,  and  attributes  his 
recovery  largely  to  the  use  of  the  iodide  of  potassium.  He 
stopped  smoking  at  the  time  of  the  paroxysms,  but  has  resunu'd 
it  since  without  any  detriment. 

In  a  disease  so  notoriously  uncertain  as  true  angina,  the 
prognosis  must  necessarily  be  most  guarded.  Fortunately,  as 
I  have  already  said,  the  character  of  the  attack  is  such  that 
the  patient  is  very  well  aware  of  the  extreme  hazard  of  his 
state.  Of  the  important  elements  in  prognosis,  the  following 
are  to  be  considered: 

The  frequency  and  severity  of  the  attacks.  Eecurrencc 
at  short  intervals  of  paroxysms  of  great  severity,  induced  by 
slight  exertion,  is  of  ill  omen,  particularly  if  with  them 
there  are  marked  cardiac  arrhythmia  and  signs  of  dilata- 
tion. 

The  existence  of  vahmlar  disease  does  not  in  itself  mate- 
rially aggravate  the  prognosis.  A  large  majority  of  the  worst 
cases  of  angina  show  no  sign3  of  valvular  lesions.  The  exist- 
ence of  aortic  disease  renders  the  patient,  of  course,  much 


PROGNOSIS  OF  ANGINA  PECTORIS. 


141 


more  liable  to  myocardial  changes  and  dilatation  and  the 
other  consequences  of  progressive  failure  of  the  muscular 
power.  The  following  is  a  remarkable  instance  of  good  health, 
even  vigor,  for  years  with  aortic-valve  disease  and  angina  of 
ten  years'  duration: 


Mr.  X.,  agod  fifty-one  years,  Ilolhrook,  Maryland,  consulted 
me  June  10,  18J)5.  His  general  health  had  always  been  good. 
So  long  as  ho  could  remember  he  had  had  heart  trouble;  he  had 
been  sliort  of  breath  on  exertion,  and  had  been  conscious,  as  he 
expressed  it,  of  a  sort  of  grinding  in  his  chest.  When  a  child 
he  had  attacks  of  extensive  blotches  on  the  skin  with  gastro- 
intestinal pain  (Henoch's  purpura).  He  had  rheumatism  when 
twenty-two,  but  no  swelling  or  redness  ^f  the  joints.  With  care 
he  has  been  able  to  get  about  and  has  lived  very  comfortably, 
though  he  has  never  been  able  to  do  heavy  work. 

He  looked  pale,  a  little  thin,  and  had  a  suggestive  cardiac 
fades;  there  were  no  signs  of  any  swelling  of  the  joints.  There 
was  nn  inguinal  hernin  on  the  right  side.  The  apex  beat  v/as  in 
the  rh  and  sixth  spaces  just  outside  the  nipple  line.  There 
was  a  1  irgo  aroii  nf  cardiac  impulse  There  was  a  loud  systolic 
murmur  at  tin  apox  region,  propagated  to  axilla  and  loudly 
along  ])ectoral  boi'lcr.  It  in(  roased  in  intensity  toward  the  left 
margin  of  sternum.  In  the  whole  apex  region  there  was  almost 
silence  in  diastole,  perhaps  a  faim  i-umblo,  and  at  ilie  apex  there 
was  a  slight  systolic  shoe  k.  Tlie  systolic  murmur  became  very 
loud  over  the  sternum,  and  attained  a  maximum  intensity  at  the 
second  right  costal  cartilage,  where  it  was  rough,  harsh,  vibra- 
tory, and  was  projiagated  will  great  intensity  into  the  vessels. 
Along  the  left  margin  of  mum  and  as  low  as  the  ensiform 
cartilage  there  was  an  extremely  soft  diastolic  murmur.  There 
was  no  pulsation  to  be  felt  in  the  sternal  notch.  The  pul- 
sation in  the  superficial  arteries  was  visible;  the  vessels  were 
a  little  stiff.  The  pulse  was  100,  not  collapsing,  of  mediun. 
volume,  and  gave  one  the  impression  of  effort. 

He  had  Ids  first  attack  of  angina  ten  years  ago,  coming  from 
Chicago.  Two  years  subsequently  ho  had  another  attack,  and 
had  to  have  morphine.    He  has  had  six  or  seven  attacks  alto- 


*       i 


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142 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


I  j 


m. 


getlicr,  the  last  one  seven  days  ago  as  lie  was  getting  out  of  bed. 
On  each  occasion  tlicre  has  been  a  single  attack;  morplilno 
alone  controls  them. 

Ten  years  ago  he  evidently  had  an  attack  of  cardiac  break- 
down, with  great  shortness  of  breath.  Subsequently,  for  three 
years,  he  took  ten  drops  of  the  tincture  of  digitalis  three  times 
a  day,  without  missing,  he  thinks,  a  single  dose.  During  the 
attack  he  feels  very  badly;  there  is  immobility  and  agonizing 
pain  in  the  chest,  he  feels  as  if  he  was  going  to  die,  and  he  sweats 
profusely. 

A  word  or  two  upon  an  ethical  problem  which  is  often 
very  perplexing — viz.,  What  is  your  duty  in  the  matter  of  tell- 
ing a  patient  that  he  is  probably  the  subject  of  an  incurable 
disease?  I  can  give  you  no  hard-and-fast  rule;  the  tempera- 
ment of  the  individual  himself,  his  associations  and  responsi- 
bilities, your  own  convictions  as  to  the  seriousness  of  the  con- 
dition— all  these  must  be  carefully  weighed.  The  question  is 
somewhat  theoretical,  since  in  reality  the  necessity  docs  not 
often  arise.  The  announcement  has  already  been  made,  for 
no  man  suffers  the  anguish  of  a  severe  paroxysm  of  angina 
without  a  consciousness  of  the  nearness  of  the  Angel  of  Death. 
We  are  sometimes,  I  confess,  placed  in  positions  of  the  utmost 
delicacy,  since  a  man  may  have  not  the  slightest  intimation  of 
his  parlous  state,  and  you  may  become  aware  of  the  urgent 
necessity  tliat  he  should  make  proper  arrangements  to  protect 
his  wife  and  children.  In  such  a  case  a  quiet  hint  as  to  the 
uncertainty  of  the  outlook  in  heart  and  artery  disease  may  be 
enough  to  set  him  a-thinking;  or,  in  the  case  of  an  "even- 
balanced  soul,"  the  whole  question  may  be  discussed  frankly. 
One  thing  is  v-ertain:  it  is  not  for  you  to  don  the  black  cap, 
and,  assuming  the  judicial  function,  take  hope  from  any  pa- 
tient— "  hope  that  comes  to  all  " — and  you  may  dwell  with 
advantage  on  the  aspects  of  John  Hunter's  case  rather  than 
on  those  of  Thomas  Arnold. 


cak- 
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lines 
the 
King 
feats 


TREATMENT  OP  TRUE  ANGINA. 


143 


Treatment. — "  The  first  and  great  object  of  the  practi- 
tioner on  being  called  on  to  treat  a  case  of  angina  will  be 
to  make  himself  acquainted  with  its  individual  character. 
Beginning  with  the  early  history  of  the  disease,  he  will  trace 
it  to  its  present  stage,  and  will  endeavor,  from  the  narrative 
of  the  patient  and  from  the  observation  of  the  whole  phe- 
nomena presented  to  him,  to  form  a  clear  judgment  respect- 
ing the  local  condition  of  the  organs  in  which  the  characteristic 
symptoms  have  their  site,  and  the  state  of  all  the  other  parts 
of  the  system  which  can  in  any  way  influence  these;  in  other 
words,  he  must  endeavor  to  ascertain  the  species  or  variety 
of  angina,  according  to  the  distinction  formerly  pointed  out." 
This  clear  statement  of  Sir  John  Forbes  forms  a  fitting  intro- 
duction to  the  discussion  of  this  part  of  our  subject.  Suc- 
cessful treatment  depends  often  upon  correct  diagnosis;  but 
there  are  cases  of  angina  pectoris  brought  to  the  consultant 
in  which  diagnosis  and  prognosis  in  themselves  constitute  the 
treatment.  To  a  man  who  has  felt  that  judgment  has  been 
given  against  him,  the  doom  pronounced,  and  whose  mind 
is  haunted  with  the  dread  of  sudden  death,  the  assurance  that 
the  condition  is  functional  and  curable  comes  as  a  reprieve, 
and  may  be  the  one  thing  necessary  to  effect  the  cure. 

True  Angina. — Determine  in  the  first  place,  if  possible, 
the  existence  of  any  constitutional  disease,  as  syphilis,  gout, 
or  diabetes,  and  the  presence  or  absence  of  vahnilar  lesions. 

{a)  General  Management. — Inquire  carefully  about  the 
exciting  causes  of  the  attacks,  which  differ  in  different  cases. 
Usually  the  patient  has  learned  by  bitter  experience  his  limita- 
tions in  certain  directions,  and  knows  much  better  than  you 
can  tfil  him  just  what  to  avoid;  but  you  can  emphasize  the 
importance  of  mental  worry,  exercise,  and  diet,  the  three  chief 
factors.  Quiet  of  mind,  avoidance  of  worries  and  cares,  the 
cultivation  of  a  calm  equanimity — with  these,  or  such  like 


I- 


11 


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■.; 

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■■( 

144 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


phrases,  we  try  to  impress  a  poor  victim  who  to  previous  anxie- 
ties has  now  the  added  burden  of  a  disease  the  terrible  char- 
acter of  which  he  can  appreciate  but  can  not  understand. 
Our  words  often  seem  a  mockery,  and  yet  they  may  be  help- 
ful in  persuading  a  man  to  cast  off  all  unnecessary  business 
and  to  live  a  life  in  which  there  shall  be  a  minimum  of  fric- 
tion. Time,  too,  with  its  soothing  deception,  comes  to  allay 
the  access  of  early  apprehension,  and  as  succeeding  attacks 
pass  there  may  be  less  and  less  mental  distress.  An  important 
question  arises  here.  Shall  a  man  with  angina  give  up  his 
business?  In  a  majority  of  cases  this  sacrifice  is  unnecessary; 
the  literature  abounds  with  examples  of  men  who,  like  John 
Hunter,  have  done  the  best  work  of  their  lives  after  the  onset 
of  angina.  There  is  so  much  uncertainty  that  no  rule  can  be 
laid  down ;  each  individual  case  must  be  considered  separately. 
The  patient's  age,  occupation,  and,  above  all,  the  condition 
of  the  vascular  system,  must  be  taken  into  account.  Even 
after  a  most  severe  attack,  followed  bv  a  cardiac  breakdown 
of  several  months'  duration,  a  man  may  be  able  to  resume 
work,  and,  as  in  Case  V,  referred  to  in  Lecture  III,  be  bene- 
fited by  the  steady  occupation. 

JExercise  must  be  taken  within  the  limits  which  each  in- 
dividual soon  learns  to  recognize.  In  severe  recurring  attacks 
induced  by  slight  muscular  efforts,  a  period  of  absolute  rest 
should  be  enjoined.  The  sudden,  quick  movements  wdiich 
rapidly  increase  the  blood  pressure  and  throw  a  strain  upon 
the  heart  arc  the  most  dangerous;  and  most  of  all  those 
with  which  are  associated  strong  emotions.  The  patient 
should  be  urged  to  walk  on  the  level,  in  the  literal  as  well  as 
metaphorical  meaning  of  the  phrase.  He  should  learn  "  to 
live  within  the  income  of  his  circulation,"  with  which  wise 
saw  from  the  lips  of  the  late  Dr.  Sibson  a  friend  with  organic 
heart  disease  has  been  comforted  and  sustained  for  a  quarter 


TRUE  ANGINA. 


145 


of  a  century.  Steady,  quiet  exercise  should  be  encouraged, 
except,  of  course,  when  there  are  special  signs  of  cardiac 
weakness,  in  which  case  the  resistance  gymnastics  of  the  Schott 
method  may  be  tried. 

Diet  is  in  man^-  c^^cs  the  central  point  in  the  treatment. 
The  subjects  of  angina  are  often  men  with  largo  appetites, 
accustomed  to  eat  freely  of  rich  and  strong  foods.  First,  limit 
the  amount  taken,  which  in  most  persons  above  forty  years 
of  age  is  far  too  great ;  second,  see  that  the  quality  is  suitable 
by  excluding  from  the  dietary  rich,  highly  seasoned  foods 
and  those  which  favor  fermentation;  and  third,  arrange  the 
hours  for  eating.  The  subjects  of  angina  are  usually  aware 
of  the  necessity  of  limiting  the  quantity  of  food  and  drink 
taken  at  one  time.  So  soon  as  the  stomach  is  distended  there 
may  be  warnings  of  distress  about  the  heart,  or  in  aggravated 
cases  a  full  meaJ  may  always  cause  an  attack.  As  one  patient 
expressed  it,  "  Had  I  not  to  eat,  I  would  never  suffer."  Light 
meals  should  be  the  rule  in  all  cases ;  at  breakfast  and  at  mid- 
day dinner  more  may  be  taken  than  at  the  evening  meal. 
Late  suppers  should  be  interdicted — there  is  "  death  in  the 
pot "  for  angina  victims,  and  a  surfeit  may  be  as  fatal  as 
poison. 

The  quality  of  the  food  is  equally  important.  Special 
dietaries  may  be  necessary  for  patients  with  gout  and  glyco- 
suria, but  in  ordinary  cases  the  food  is  to  be  regulated  with 
reference  to  one  all-important  feature — viz.,  flatulence.  As 
you  may  remember,  almost  every  one  of  the  old  writers  laid 
the  greatest  stress  upon  this  element  in  the  causation  of  the 
attacks,  and  they  were  right.  In  dealing  with  the  question  of 
diet  we  are  too  apt  to  adopt  some  fad  to  which,  with  Pro- 
crustean precision,  we  fit  every  case.  A  more  rational  way  is 
to  recognize  the  extraordinary  peptic  diversity  in  our  patients 
— in  no  respect  more  strikingly  shown  than  in  this  very  mat- 


fii 


1     r 

11 


I 


14G 


ANOIXA  PECTORIS  AND  ALLIED  STATES 


I   i 


w 


ter  of  flatulency.  Beyond  the  generally  accepted  restriction 
of  the  carhohydrates  we  can  not  go  very  far  without  meeting 
individual  peculiarities  which  have  to  be  considered.  The 
patient  himself  has  to  he  consulted  carefully.  Some  of  you 
may  call  to  mind  what  orr  distinguished  colleague  Dr.  Smol- 
lett makes  one  of  his  characters,  ^latt.  Braiid)le,  say  in  Ilt/m- 
phrey  Cllnl'er:  ''  For  my  own  part,  I  have  had  a  hospital  these 
fourteen  vears  within  nivself,  and  studied  my  own  case  with 
the  most  painful  attention,  conse(|uently  may  be  supposed  to 
know  something  of  the  matter."  AVe  are  too  apt  to  forget 
this.  An  intelligent  man  should  be  able  to  tell  you  just  what 
articles  of  food  cause  most  disturbance  and  produce  wind  in 
the  stomach  or  bowels.  The  fault  may  not  lie  in  the  food, 
but  in  the  inability  of  the  stomach  and  bowels  to  digest  it  prop- 
erly. The  obese,  flabby  subjects  of  angina — not  the  most 
numerous  class  in  my  exiJcrience — and  those  with  weak  heart 
and  arterio-s(derosis  are  specially  prone  to  flatulence.  A  few 
doses  of  blue  mass,  an  occasional  saline  purge,  and  the  use  at 
times  of  a  good  bitter  tonic  keep  this  condition  in  check.  The 
use  of  hot  w\ater  before  meals,  particularly  before  breakfast, 
has  been  found  very  serviceable. 

In  elderly  men  accustomed  to  stimulants,  hot  grog  at  bed- 
time allavs  the  tendcncv  to  flatulencv,  which  is  sometimes 
the  cause  of  wakefulness,  or  which  is  apt  to  disturb  the  pa- 
tient in  the  early  morning  hours.  Peppermint,  spirits  of  cam- 
phor, Hoffmann's  anodyne,  carbolic  acid,  iodine,  and  creosote 
are  useful  for  "  wind  on  the  stomach."  For  the  intestinal 
flatulencv  a  saline  purge  is  often  a  good  corrective;  the  vari- 
ous supposed  intestinal  disinfectants  may  be  tried — salol,  beta- 
naphthol,  and  corrosive  sublimate,  of  which  pilules  of  from 
one  sixtieth  to  one  thirtieth  of  a  grain  may  be  given  sometimes 
with  advantage. 

(J)  General  Medical  Treatment. — Of  constitutional  con- 


GENERAL  MEDICAL  TREATMENT. 


147 


Ion 

[ho 
[•on 
lol- 
vm- 
Icsc 
fitli 
to 


(litions  underlying  angina  pectoris  and  capaMe  of  treatment, 
syphilis  and  gout  arc  the  most  imi»ortant.  (Jenuine  angina 
in  a  man  under  thirty-five  years  of  age  should  arouse  a  sus- 
picion of  syphilis,  and  vigorous  measures  should  be  adopted. 
In  gouty  cases  free  elimination  by  the  bowels,  skin,  and  kid- 
neys should  be  secured,  a  proper  diet  ordered,  and  at  intervals 
a  course  of  colchicum  may  be  prescribed. 

One  patient,  Dr. ,  emphasized  repeatedly  the  benefit 

he  had  derived  from  colchicum.  Stimulants  should  be  avoided. 
Glycosuria  is  usually  controlled  by  diet,  and  rarely  gives  much 
trouble. 

In  a  large  proportion  of  all  cases  of  angina  pectoris  the 
treatment  consists  in  the  administration  of  the  iodides  and 
nitrites,  remedies  which  are  believed  to  influence  arterial  func- 
tion and  arterial  mitrition.  The  use  of  the  iodides  of  potas- 
sium and  sodium  in  this  disorder  has  been  advocated  most 
warmly  by  Iluchard,  who  states  that  of  eighty  patients  with 
organic  angina  treated  thoroughly  by  these  drugs  twenty- 
two  recovered,  forty-three  were  greatly  benefited,  and  fifteen 
died.*  The  iodides  appear  to  have  a  beneficial  effect  in  check- 
ing or  modifying  the  progress  of  arterio-sclerosis  and  in  lower- 
ing the  blood  pressure.  They  may  influence,  too,  arterial 
pain.  I  have  called  your  attention  repeatedly  to  the  influence 
of  iodide  of  potassium  in  aneurysm  of  the  aorta,  in  whicli  the 
relief  of  the  pain  is  one  of  its  most  striking  effects.  AVhile  I 
can  not  say  that  my  experience  is  in  every  way  so  favorable  as 
Iluchard's,  I  can  testify  to  the  great  relief  which  has  followed 
its  use  in  many  cases,  and  in  a  few  an  apparent  cure.  Cases 
whicli  were  thoroughly  treated  nearly  ten  years  ago  remain 
quite  well,  and  I  have  had  within  the  past  three  years  several 
patients  who  have  been  greatly  benefited.     I  usually  order 

*•■  Le  Traitement  de  Vangine  de  poitrine,  Paris,  1892. 


Si 


V 


148 


ANOIXA  PECTORIS  AND  ALLIED  STATES. 


I   ; 


the  iodide  of  potassium  in  doses  of  ten  or  fifteen  grains  three 
times  a  day.  Should  it  disauree,  wliich  is  very  seldom,  I  give 
the  sodium  salt.  Larger  doses  are  not  often  neeessary.  If 
intolerance  develops,  stop  the  use  for  a  week  and  begin  with 
smaller  doses.  The  success  in  treatment  depends  upon  the 
perseverance  with  which  the  drug  is  used.  On  this  point  let 
me  quote  from  Iluchard's  pamphlet:  "One  of  the  principal 
conditions  of  success  is  perseverance — constancy  in  the  medi- 
cation. The  drug  nnist  bo  taken  for  a  j)eriod  of  two  to  four 
years,  in  daily  doses  of  one  to  three  grammes,  until  all  symp- 
toms of  angina  have  disa])peared  for  many  months,  and  I  hold 
that  a  permanent  and  definitive  recovery  is  not  obtainable 
except  after  many  years  of  treatment."  Reasonable  caution 
must  be  employed,  and  you  would  not  give  the  iodi<les  in  pa- 
tients with  advanced  arterial  degeneration,  a  dilated  heart, 
and  signs  of  interstitial  nephritis.  The  patients  who  stand  the 
treatment  well  are  the  robust,  middle-aged  men  in  whom  the 
angina  is  the  sole  symptom.  AVith  aortic  disease,  if  fairly 
compensated,  the  drug  may  be  used. 

The  nitrites  in  hypertension  and  angina  pectoris  are  of 
value  quite  equal  to  the  iodides.  The  nitrite  of  amyl  is  em- 
ployed in  the  paroxysm.  The  nitroglycerin  or  trinitrin  is 
indicated  in  all  cases  in  which  the  tension  is  persistently  high. 
Given  properh',  it  is  a  very  valuable  remedy,  l)ut  to  get  any 
advantage  from  its  use  each  case  must  be  taken  by  itself. 
In  the  first  place,  be  sure  that  the  nitroglycerin,  cither  in 
solution  or  tablets,  is  fresh.  The  tablets  containing  one  one- 
hundredth  of  a  grain  are,  as  a  rule,  reliable.  It  is  well  to 
begin  with  only  one  of  these  three  times  a  day.  The  dose 
may  be  increased  gradually  until  the  patient  takes  four  or  five 
three  times  a  day,  or  even  a  larger  dose.  If  the  patient  notices 
a  slight  glow  or  flush  and  a  little  sensation  of  fullness  in  the 
head  you  may  know  that  the  remedy  is  acting.    I  feel  sure 


i 


TREATMENT  OF  THE  ATTACK. 


149 


tliat  in  individual  cases  we  often  do  not  employ  the  drug  in 
sufficient  doses.  I  have  never  seen  it  do  any  harm.  The  ex- 
treme flushing  and  throbbing  headache  give  reliable  indica- 
tions when  the  limit  has  been  reached.  I  have  given  as  much 
as  thirty  minims  of  the  one-per-cent.  solution,  three  times  a 
day,  to  a  case  of  chronic  arterio-sclerosis,  without  any  disturb- 
ance. The  nitrite  of  sodium,  recommended  by  Ilay,  may  also 
bo  tried  in  doses  of  five  to  ten  grains  three  times  a  day. 

Among  other  remedies  which  are  useful  in  the  general 
medical  treatment  of  angina,  arsenic  is  sometimes  very  valu- 
able. Balfour  advises  it  i)articularly  in  the  weak  heart  of 
elderly  peojde,  when  associated  with  pain  of  any  kind.  In 
cases  of  feeble  heart  with  anicmia,  iron  and  strychnine  are 
most  valuable  remedies,  and  in  order  not  to  trouble  the  patient 
with  too  many  doses,  arsenic,  iron,  and  strychnine  may  be 
given  together  in  compressed  powder  or  pills. 

(c)  Treatment  of  the  Attack. — So  fre<piently  is  the  parox- 
ysm excited  by  gastro-intestinal  disturbances  that  the  sub- 
jects of  angina  should  not  only  be  warned  to  be  on  their 
guard  in  this  matter,  but  should  be  prepared  to  take  prompt 
measures  on  the  first  indication  of  any  distress.  Xo  doubt 
it  was  from  this  standpoint  that  W.  W.  Ord  made  the  some- 
what paradoxical  remark  that  if  restricted  to  the  use  of  one 
drug  in  angina  he  Avould  prefer  sulphate  of  magnesium  to 
nitrite  of  amyl.  A  patient  should  be  told  to  use  a  saline  purge 
or  blue  mass  or  small  doses  of  calomel  when  he  feels  gastro- 
intestinal uneasiness.  It  frequently  happens  that  much  more 
prompt  treatment  is  necessary  for  a  condition  of  flatulency. 
lie  should  be  provided  with  Iloflfmann's  anodyne  and  spirits 
of  camphor;  a  teaspoonful  of  each  in  some  peppennint  water 
or  hot  whisky  makes  an  excellent  carminative  draught.  The 
combination  of  mor})hine,  cannabis  indica,  hyoscyamus,  cap- 
sicum, peppermint,  and  spirits  of  chloroform  which  is  now  pre- 


1^"' 


I 


i 


hi 


i 


i 

i 

Ir. 

160 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


pared  c'itlicr  in  liiiuid  or  tablet  form  as  clilorodyno  is  sonio- 
tiuios  very  advantageous.  In  tablet  form  it  is  particM.larly 
convenient,  as  it  may  be  carried  in  the  waistcoat  pocket. 
For  tli(!  paroxysm  itself  there  are  three  remedies: 
Xitrite  of  amyl,  two  to  live  minims,  iiduih'd  from  a  hand- 
kerchief, or  from  cotton  wool  i)Iaced  at  the  bottom  of  a  wine- 
glass, gives  promi)t  relief  in  certain  cases.  The  i)atients  are 
in  the  habit  of  carrying  the  remedy  in  i>ei'le8  containing 
three  to  five  niininis,  which  can  bo  rai)idly  broken  in  a  hand- 
kerchief and  inhaled  so  soon  as  the  very  earliest  symptoms  of 
the  attack  are  noticed.  The  introdncti<m  of  this  drng,  in  the 
treatment  of  angina,  by  Dr.  Lander  15rnntoi)  has  certainly 
been  a  gi-eat  boon  to  many  snfTerers,  bnt  too  mncl!  must  not  be 
expected  of  it.  It  is  singularly  uncertain.  Wiiile  in  one 
case  t'le  attacks  are  promptly  cut  short  and  almost  innnediatc 
relief  obtained,  in  others  it  seems  (piite  ii.'Tt.  Curiously 
enough,  considering  that  its  physiological  eiicct  is  in  dilating 
the  peripheral  vessels  and  relieving  the  widespread  angeio- 
spasm,  in  my  experience  it  has  been  less  efficacious  in  the 
vaso-motor  type  of  the  disease  than  in  eases  of  organic  angina. 
It  may  ]>roduce  its  effect  with  great  ra])idity,  as  shown  by  the 
flushed  face  of  the  patient  and  the  increased  volume  and  soft- 
ness of  the  ])ulse,  witlumt  relieving  the  pain.  It  sometimes 
acts  better,  given  by  the  mouth,  combined  with  the  tincture 
of  capsicum  in  peppermint  water. 

!^^orphine  hypodermically  is  the  most  useful  drug  in  the 
attack,  and  if  the  pain  is  not  relieved  quickly  by  the  nitrite 
of  amyl  an  injection  of  a  quarter  of  a  grain  should  be  given, 
and  re]K>ated  in  a  half  or  three  quarters  of  an  hour  if  the 
patient  is  not  relieved.  In  one  case  the  nitrite  of  amyl  failed 
repeatedly  to  give  the  slightest  relief,  but  from  a  quarter  to  a 
third  of  a  grain  of  morphine,  liypodermically,  never  failed 
to  allay  the  terrible  distress,  and  seemed  also  to  steady  and  im- 


TRKATMKXT  OF  THE  COMPLICATIONS. 


151 


prove  tlie  heart's  nction.  A  point  about  the  use  of  morpinno 
in  angina  which  I  have  never  «een  mentioned  except  in  tlio 
jMiper  by  Dr.  Ii»irney  Yeo  in  the  PradUlonar,  already  re- 
ferred to,  irt  the  reinnrkahh'  toh'ranco  of  ni<>ri)hine  in  certain 
cases.  In  re})(»rting  Case  XXXll  1  mentioned  tliat  this  pa- 
tient received  between  ten  oVdock  on  Saturday  nip,ht  and  1 
I*.  ,M.  on  Sninhiy  five  grains  of  morphine  liypodermically  and 
by  tile  moutli,  winch  relieved  the  pain  but  did  not  give  him 
sleej).  Inhere  are  cases  in  which  a  hyi)odermic  injection  of  a 
quarter  of  a  grain  of  morphine  given  at  the  first  indication  of 
the  attack,  as  a  nnnd)ness  in  the  hand  or  tingling  in  the 
fingers,  checks  it  at  once. 

And  third,  in  any  jiaroxysm  of  great  intensity,  while 
waiting  for  the  nitrite  of  amyl  or  mor])hine  to  take  effect, 
chloroform  may  be  droj)ped  u])on  a  handkerchief  and  iidialcd. 
Balfour  recommends  that  it  be  poured  on  a  sjxnige  in  a  smell- 
ing bottle,  and  the  patient  t(d(l  to  breathe  it  through  the  nose 
as  deeply  as  possible.  In  a  minute  or  two  relief  is  obtained, 
and  as  the  patient  comes  under  the  influence  of  the  drug 
the  bottle  drops  from  his  hand,  and  there  is  in  this  way  no 
dani>(>r  of  an  overdose.  The  chloroform  acts  much  more 
promptly  and  is  much  ])leasanter  to  take  than  other,  and  I 
have  never  seen  any  dangerous  effects  from  its  use,  even  in 
persons  with  very  weak  heart's  action. 

{(I)  Treatment  of  the  Co?)}j)lf  cat  ions. — For  the  syncope 
of  serious  attacks  the  aromatic  spirits  of  ammonia  with  Hoff- 
mann's anodyne  and  brandy  may  be  given,  or  hypodermic 
injections  of  ether  or  camphor.  For  the  dilatation  of  the 
heart  and  cardiac  weakness,  whic.i  sometimes  follow  the  at- 
tack, the  nitroglycerin  with  strong  fr>tions  to  the  limbs  may 
favor  the  circulation  at  the  periphery,  while  digitalis  or  digi- 
talin  may  be  given  freely  to  stimulate  the  heart's  action. 
Digitalin  sometimes  acts  well,  as  in  Case  XXXVIII,  and  may 


(' 


II 


152 


ANGINA  PECTORIS"  AND  ALLIED  STATES. 


I  fit 


II 


fli 


be  given  livpoclcrmically.  Ko  hard-and-fast  rule  can  bo  laid 
down  regarding  the  use  of  digitalis.  It  sometimes  acts  badly, 
as  in  a  case  very  carefully  studied  by  AV.  T.  Sharplcss,  of 
West  Chester.  Caffeine  and  camphor  may  also  be  employed. 
If  all  these  measures  seem  futile,  I  would  not  hesitate  to  em- 
ploy puncture  of  the  heart — cardiocentesis — which  may 
arouse  to  (juite  vigorous  action  a  dilated  and  paretic  organ. 
I  do  not  know  that  this  has  been  employed  in  the  cardiac 
asystole  following  a  severe  paroxysm  of  angina,  but  there  are 
instances  on  record,  notably  the  case  of  Sloane  {Edhihnrgh 
3fedicalJournaly\o\.  xl),  in  v;hich  puncture  of  the  heart  with 
a  needle  driven  firmly  into  the  ventricle  has  aroused  the  flag- 
ging action  apparently  without  doing  the  slightest  injury. 

For  the  condition  of  chronic  ttat  de  mat  amjlneux^  in 
which,  for  a  period  of  many  days  or  even  weeks,  the  patient 
has  recunnng  attacks  with  cardiac  asthma  and  feebleness  of 
the  circulation,  yor.v  resources  will  be  taxed  to  the  uttermost. 
For  the  dyspnoea  ai\d  the  Cheyne-Stoke'^,  breathing  full  doses 
of  strychnine,  hyix»dermically,  may  be  employed,  from  a  for- 
tieth to  a  twentieth  of  a  grain,  threo  or  four  times  a  day. 
Special  care  should  be  taken  that  the  bowels  are  ke{)t  freely 
opened.  The  cardiac  measures  already  spoken  of  may  be  em- 
ploye d,  and  flying  blisters  to  the  prsrcordia  and  tj  the  bases 
of  the  Irngs  may  sometimes  give  relief. 

Trealv.icnt  of  Pseudo-angina  Pectoris. — The  measiires 
Uiust  usually  be  directed  to  combating  the  underlying  con- 
dition of  neurasthenia  or  hysteria.  Occcasionally  it  hapjiens, 
particularly  in  medi.-al  men,  that  the  mental  relief  afforded 
by  a  positive  diagnos'o  of  pseudo-angina  is  in  itself  suflicicnt  to 
effect  a  cure.  Cases  II  and  III,  given  in  Lecture  V,  are  good 
illustrations  of  the  improvement  and  permanent  cure,  up  to 
the  present  date,  of  attacks  of  maximum  severity.  It  is  not 
easy  to  say  to  what  the  rapid  relief  could  be  attributed,  as  the 


TREATMENT   OP  PSEUDO-ANGINA  PECTORIS.  153 

patients  were  given  only  general  tonics.  In  other  cases  the 
attacks  recur  for  years,  as  in  the  wife  of  the  physician  from 
the  Province  of  Quebec,  of  whom  I  spoke,  who  had  had 
attacks  for  twenty-five  or  thirty  years.  In  the  severe  form, 
particularly  when  associated  with  much  vaso-motor  disturb- 
ance, the  Weir  Mitchell  treatment  may  be  tried  with  ad- 
vantage. The  effects  of  seclusion,  systematic  massage,  and 
electricity,  particularly  t)ie  static  form,  are  sometimes  most 
satisfactory.  Where  this  is  not  feasible  hydrotherapy  should 
be  tried,  either  a  systematic  course  at  some  institution,  or, 
if  this  is  not  practicable,  the  systematic  use  of  the  wet  pack 
at  night,  followed  by  thorough  friction,  will  bo  found  advan- 
tageous. Some  of  these  cases,  particularly  if  treated  at  the 
patient's  home,  tax  to  the  uttermost  the  resources  of  the  physi- 
cian. Tl\e  change  of  air  and  scene  in  traveling  will  often 
be  found  of  advantage. 

Drugs  are  of  uncertain  and  doubtful  benefit.  We  often 
have  to  order  the  bromides  and  valerian,  and  in  cases  with 
much  cardiac  irritability  and  vaso-motor  disturbance  the  use 
of  nitroglycerin  in  large  doses  seems  sometimes  to  aid  in 
equalizing  and  steadying  the  circulation.  In  looking  over  the 
notes  of  my  cases  of  pseudo-angina  I  notice  this  hopeful 
feature,  that  with  but  one  or  two  exceptions  the  patients  are 
at  present  not  only  alive  and  well,  but  free  from  attacks. 

When  the  attacks  of  angina  are  due  to  the  abuse  of  to- 
bacco, the  patient  should  give  up  the  habit  entirely.  I  do  not 
think  there  is  much  risk,  either,  in  stopping  abruptly. 
Counter-irritation  over  the  heart  by  means  of  the  Paquelin 
cautery  or  blisters,  the  use  of  strychnine  in  full  doses,  and,  if 
the  pulse  tension  is  high,  of  nitroglycerin,  are  measures  which, 
will  be  found  ifficacious. 


In  the  worry  and  strain  of  modem  life  arterial  degcnera- 
11 


154 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


^ 


ii 


.1 


a 


^y 


kf'ii 


Ii 


-li'i 


tion  is  not  only  very  common,  but  develops  often  at  a  rela- 
tively early  age.  For  this  I  believe  that  the  high  pressure  at 
which  men  live,  and  the  habit  of  working  the  machine  to  its 
maximum  capacity,  are  responsible,  rather  than  excesses  in 
eating  and  drinking,  or  than  any  special  prevalence  of  syphi- 
lis. Angeio-sclerosis,  creeping  on  slowly  but  surely,  "  with  no 
pace  perceived,"  is  the  Nemesis  through  which  Nature  ex- 
acts retributive  justice  for  the  transgression  of  her  laws — 
coming  to  one  as  an  apoplexy,  to  another  as  an  early  Bright's 
disease,  to  a  third  as  an  aneurysm,  and  to  a  fourth  as  angina 
pectoris,  too  often  slitting  "  the  thin  spun  life  "  in  the  fifth 
decade,  at  the  very  time  when  success  seems  assured.  ^No- 
where  do  we  see  such  an  element  of  tragic  sadness  as  in  many 
of  these  cases.  A  man  who  has  early  risen  and  late  taken  rest, 
who  has  eaten  the  bread  of  carefulness,  striving  for  success 
in  commercial,  professional,  or  political  life,  after  twenty- 
five  or  thirty  years  of  incessant  toil  roaches  the  point  where 
he  can  say,  perhaps  with  just  satisfaction,  "  Soul,  thou  hast 
much  goods  laid  up  for  many  years:  take  thine  ease,"  all  un- 
conscious that  the  fell  sergeant  has  already  isf  ued  the  warrant. 
How  true  to  life  is  Hawthorne  in  the  lionise  of  the  Seven 
Gables!  To  Judge  Pyncheon,  who  had  experienced  a  mere 
dimness  of  sight  and  a  throbbing  at  the  heart — nothing  more 
— and  in  whose  grasp  was  the  meed  for  which  he  had  "  fought 
and  toiled  and  climbed  and  crept ";  to  him,  as  he  sat  in  the 
old  oaken  chair  of  his  grandfathers,  thinking  of  the  crown- 
ing success  of  his  life,  so  near  at  hand,  the  avenger  came 
through  the  arteries. 

"  With  wdiat  strife  and  pains  we  come  into  the  world  wo 
know  not,  but  it  is  commonly  no  easy  matter  to  get  out  of  it," 
Sir  Thomas  Browne  says;  and,  having  regard  to  the  uncer- 
tainties of  the  last  stage  of  all,  the  average  man  will  be  of 
Caesar's  opinion,  who,  when  questioned  at  his  last  dinner  party 


CONCLUSION. 


155 


as  to  the  most  preferable  mode  of  deaiu,  replied — "That 
which  is  the  most  sudden."  Against  this,  one  in  a  string  of 
grievous  calamities,  we  pray  in  the  Litany,  though  De  Quincy 
insists  that  the  meaning  here  is  "  unpiepared."  In  this  sense 
sudden  death  is  rare  in  angina  pectoris,  since  the  end  comes 
but  seldom  in  the  first  paroxysm.  Terrible  as  are  some  of 
these  incidental  conditions  accompanying  coronary  artery 
lesions,  there  is  a  sort  of  kindly  compensation,  as  in  no  other 
local  disease  do  we  so  often  see  the  ideal  death— death  like 
birth  "  a  sleep  and  a  forgetting." 


H 


APPENDIX. 


NOTE  A. — Rougnon's  claim  (page  6). 

"While  these  lectures  were  in  course  of  publication  in  the 
New  York  Medical  Journal  I  had  the  following  explanatory 
letter  from  Professor  Gairdner,  which  it  is  only  due  to  him  to 
publish: 

225  St.  Vincent  Street,  Glasgow,  Sept.  SS,  1896. 

My  dear  Osler:  I  have  only  to-day  had  my  attention 
directed  to  your  most  interesting  lectures  on  angina  pectoris  in 
the  New  YorTc  Medical  Journal,  and  while  appreciating  them 
very  much,  I  must  confine  my  remarks  to  one  point  at  present, 
on  which  I  have  no  doubt  you  will  desire  to  have  my  opinion 
inasmuch  as  you  have  formally  indicated  your  own  as  differing. 
(Page  178,  column  2,  as  to  the  case  of  M.  Charles.) 

The  cause  of  the  difference,  however,  is  this:  I  was  curious 
to  see  the  original  paper  of  Rougnon,  and  when  in  Paris  made 
a  special  inquiry  after  it,  in  vain,  both  in  the  Biblioth^que  Ra- 
tionale, and  in  the  library  of  the  Ecole  de  Medecine  (I  think). 
I  afterward  engaged  M.  Lereboullet  in  the  search,  and  he  was 
kind  enough  to  hunt  up  for  me  what  he  thought  to  be  the  only 
copy  accessible  after  considerable  research  (I  think  it  was  at 
Besangon,  but  am  not  sure).  He  further  was  good  enough  to 
copy,  or  get  copied,  for  me  all  that  he  thought  essential  in  the 
paper,  and  sent  it  over  with  the  remark  that  lie  could  find  noth- 
ing like  A.  P.  in  it.  To  me  it  was  just  the  same,  but  as  I  unfor- 
tunately mislaid  his  extract  I  could  not  precisely  refer  to  it  in 
writing  to  the  Lancet 

167 


158 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


You  have  been  more  fortunate  in  finding  what  I  can  not  help 
supposing  to  be  a  quite  different  document  in  your  marvelous 
library  at  Washington.  I  can  only  plead  that  my  remarks  applied 
quite  correctly  to  the  extract  sent  to  me,  and  I  should  be  glad 
if  this  were  made  clear,  though  I  can  not  now  fully  explain  it. 

Have  you  any  idea,  in  America,  as  to  the  proper  pronuncia- 
tion of  angina?  For  years  I  always  pronounced  it  with  the  i 
long,  and  never  once  heard  it  otherwise  till  Dr.  Houghton,  of 
Dublin,  pulled  me  up.  I  then  made  an  elaborate  inquiry  into 
the  classical  authorities,  and  found  that  it  comes  out  apparently 
clearly  that  the  i  is  short,  as  in  the  test  passage  in  Plautus's 
Trinummus,  which  has  been  annotated,  so  my  colleague  Pro- 
fessor Ramsey  tells  me.  Is  it  worth  while  to  make  the  change? 
In  haste, 

Yours  very  truly,  W.  T.  Gairdner. 


si 


'?« 


NOTE  B. — THE  CASE  OF  MR.  MATTHEW  ARNOLD  (PAGE  25). 

Matthew  Arnold,  the  distinguished  son  of  Dr.  Thomas 
Arnold,  died  suddenly  on  Sunday  afternoon,  April  15,  1888, 
in  his  sixty-sixth  year.  The  various  stages  in  the  progress  of 
his  disease  are  well  given  in  his  letters.  The  first  intimation 
we  have  of  any  trouble  is  in  a  letter  to  his  son,  dated  May,  1885: 
"  I  have  been  having  a  horrid  pain  across  my  chest,  and  on 
Friday  mamma  carried  me  to  Andrew  Clark,  who  has  put  me 
on  the  strictest  of  diets  for  one  week — no  medicine,  but  soup, 
sweet  things,  fruit,  and,  worst  of  all,  all  green  vegetables 
entirely  forbidden,  and  my  liquors  confined  to  one  small  half 
glass  of  brandy  with  cold  water  at  dinner.  I  am  to  see  how  this 
suits  me.  He  thinks  the  pain  is  not  heart,  but  indigv»stion. 
At  present  I  feel  very  unlike  lawn  tennis,  as  going  fast  or  going 
uphill  gives  me  the  sense  of  having  a  mountain  on  my  chest; 
luckily,  in  fishing,  one  goes  slow  and  stands  still  a  great  deal."  "• 

To  his  daughter  about  the  same  time  he  writes:  "  I  can  not 
get  rid  of  the  ache  across  my  chest  when  I  walk;  imagine  my 
having  to  stop  half  a  dozen  times  in  going  up  to  Pains  Hill! 
What  a  mortifying  change  1     But  so  one  draws  to  one's  end." 

On  August  26th  he  writes  to  his  wife  from  Wales:  "  On  the 


I 


APPENDIX. 


159 


whole,  I  did  more  yesterday,  and  did  it  easier,  than  I  have  done 
since  I  was  first  visited  by  this  pain." 

On  January  11,  1886,  in  a  letter  to  his  daughter,  he  writes: 
"  I  got  on  very  well,  and  the  skating  did  not  bring  on  the  chest 
pain;  smooth  motion  does  not,  but  laborious  motion — making 
my  way  uphill  or  through  snow." 

During  his  second  visit  to  America  in  1886  he  had  a  very 
narrow  escape  from  drowning.  "  The  accident  was  nothing;  a 
wave  carried  me  heavily  against  a  taut  rope  under  water,  put 
there  for  the  safety  of  bathers;  but  the  shock  exhausted  me 
rather,  and  was  followed  by  a  week  or  so  of  troublesome  attacks 
of  pain  across  the  chest." 

On  November  27tli  of  the  same  year  he  writes  to  his 
daughter:  "  I  am  quite  my  old  self  again — walked  about  Lon- 
don all  yesterday  in  the  fog  without  choke  and  pain." 

On  December  2 2d,  in  a  letter  to  Professor  Norton,  he  writes: 
"If  I  go  too  quick  I  am  stopped  by  a  warning  in  my  chest; 
but  I  can  go  about  as  much  as  I  like  if  I  go  leisurely,  and  I  have 
no  attacks  of  sharp  pain.  There  were  some  nights  in  America 
when  I  thought  that  my  '  grand  climacteric ' — an  epoch  in  life 
which  I  used  to  hear  a  great  deal  of  from  my  dear  mother — 
would  see  the  end  of  me;  and  I  think,  by  the  way  you  looked 
at  me  once  or  twice  at  Ashfield,  you  thought  so  too." 

In  a  letter  to  Mrs.  Coates,  January  29, 1887,  he  wrote:  "  One 
should  try  to  bring  one's  self  to  regard  death  as  a  quite  natural 
event,  and  surely  in  the  case  of  the  old  it  is  not  difficult  to  do 
this.  For  my  part,  since  I  was  sixty  I  have  regarded  each  year, 
as  it  ended,  as  something  to  the  good  beyond  what  I  could  natu- 
rally have  expected.  This  summer  in  America  I  began  to  think 
that  my  time  was  really  coming  to  an  end.  I  had  so  much  pain 
in  my  chest,  the  sign  of  a  malady  which  had  suddenly  struck 
down  in  middle  life,  long  before  they  came  to  my  present  age, 
both  my  father  and  grandfather." 

In  a  letter  to  Professor  Norton  he  again  refers  to  the  "  bad 
attacks  of  pain  while  I  was  with  you,  the  worst  I  had  in  America, 
the  worst  I  have  ever  had." 

There  are  no  further  references,  and  we  know  that  he  went 
down  to  Liverpool  to  meet  the  steamer  Aurania,  and  on  Sun- 


160 


ANGINA  PECTORIS  AND  ALLIED  STATES. 


day  afternoon,  April  15,  1888,  died  suddenly  in  liia  sixty-sixth 
year,  about  three  years  after  the  first  manifestations  of  angina. 


f 


111 


M!: 


NOTE  c. — hetextion  of  consciousness  after  apparent 

CESSATION    OF   IIEART's   ACTION    (PAGE    55). 

A  very  remarkable  fact  in  certain  cases  of  angina  is  the  per- 
sistence of  consciousness,  with  the  ability  to  engage  in  con- 
versation and  even  to  walk,  after  pulsations  have  ceased  at  the 
wrist,  or  even  after  the  heart  beats  can  no  longer  be  felt.  Dr. 
Macrae,  of  Council  Bluffs,  has  sent  me  notes  of  the  following 
remarkable  instance  of  the  kind.  A  physician  who  had  been 
the  subject  of  angina,  while  waiting  for  Dr.  Macrae  in  his  re- 
ception room,  was  seized  with  an  attack.  "  When  I  came  into 
the  room  he  was  unconscious,  with  his  head  dropped  over  the 
back  of  the  chair.  He  was  pulseless;  no  cardiac  sound  could  be 
heard.  He  regained  consciousness  and,  with  my  assistance, 
walked  into  the  other  room  and  lay  upon  the  lounge.  Careful 
examination  again  failed  to  reveal  any  cardiac  movements.  He 
was  not  in  pain,  was  sensible,  but  seemingly  dazed.  He  asked 
me  whether  his  heart  had  ceased  action.  I  told  him  it  had.  He 
gave  a  short  loving  message  to  his  wife,  ejaculated,  '  Lord  have 
mercy  on  mc! '  became  unconscious,  and  died  then  in  a  few  sec- 
onds. He  must  have  lived  at  least  five  minutes  after  I  found 
him.  When  laid  on  the  lounge  he  burst  into  a  most  profuse 
perspiration,  and  breathing  was  somewhat  labored.  The  point 
I  wish  to  make  is  that  he  lived,  was  rational,  could  almost  walk 
by  himself,  and  talked  for  several  minutes  after  his  heart,  so 
far  as  could  be  determined,  had  ceased  to  beat."  In  Case  XXIII 
I  was  very  much  impressed  by  this  retention  of  complete  con- 
sciousness and  capability  of  engaging  in  conversation  when  the 
pulse  at  the  wrist  could  not  be  felt. 


a 
g 
V 
i 
r 
\ 


nii  i 


:i\ 


THE  END. 


!i:!  4 


Cifl 


a 

I. 

0 

e 


[1 


MEDICAL  GYNECOLOGY: 

A  TREATISE   ON  THE   DISEASES  OF  WOMEN 
FROM  THE  STANDPOINT  OF  THE  PHYSICIAN. 

By  Alexander  J.  C.  Skene,  M.  D., 

Professor  of  Gynecology  in  the  Long  Island  College  Hospital,  Brooklyn,  N.  Y.  ; 

formerly  Professor  of  Gynecology  in  the  New  York  Post-Graduate  Medical 

School  ;   Gynecologist  to  the  Long  Island  College  Hospital,  etc. 

8vo,  ^j6  pages.     With  Illustrations.     Cloth,  $^.oo. 

"  The  direction  of  modern  gynecology  has  been  almost  entirely  surgical, 
and  it  is  really  refreshing  to  open  a  book  of  this  description.  The  distin- 
guislisd  author  has  filled  a  much-felt  want  in  placing  this  volume  before  the 
profession.  .  .  .  Dr.  Skene  has  covered  an  almost  untrodden  ground,  the  great 
importance  of  which  can  not  be  too  highly  appreciated.  This  work  com- 
mends itself  not  only  to  the  general  practitioner  but  to  the  specialist  as  well, 
who  will  find  in  its  pages  much  important  information." — A.inals  of  Gynecology 
and  P<ediatry, 

"  If  by  the  publication  of  this  book  Dr.  Skene  accomplishes  no  more  than 
to  direct  attention  to  the  possibilities  of  the  medical  treatment  of  gynecological 
cases,  and  to  divert  the  minds  of  practitioners,  especially  the  younger  ones, 
from  the  idea  that  only  from  surgery  is  relief  in  these  cases  to  be  looked  for, 
he  will  do  the  profession  and  the  public  an  inestimable  service.  We  predict 
for  the  volume  a  cordial  reception  on  the  part  of  the  profession  wherever  its 
merits  are  known,  for  there  is  no  other  book  of  recent  date  which  treats  these 
subjects  in  the  same  practical  and  common-sense  manner." — Brooklyn  Medical 
Journal. 

"  In  the  rapid  development  of  gynecology  during  recent  years,  the  surgical 
side  of  the  subject  has  received  the  larger  share  of  attention,  thus  in  a  measure 
leading  to  its  neglect  from  a  medical  standpoint.  This  excellent  addition  to 
the  literature  of  medical  gynecology  will  aid  in  correcting  this  tendency  and 
maintaining  a  just  balance  between  the  medical  and  surgical  phases  of  this 
department  of  our  art.  .  .  .  The  work  is  an  able  and  well-written  presentation 
of  the  subject,  and  will  no  doubt  be  received  with  the  high  degree  of  favor 
accorded  to  the  various  contributions  of  the  author  to  surgical  gynecology." 
— Memphis  Medical  Monthly. 

"  We  have  never  read  a  more  entertaining  and  profitable  book.  The  pur- 
pose of  its  popular  author  in  contributing  this  his  latest  volume  on  gynecol- 
ogy is  to  outline  the  purely  medical  aspect  of  the  subject,  and  especially  to  draw 
the  line  clearly  between  medical  and  surgical  indications  for  treatment.  .  .  . 
The  general  principles  underlying  heredity,  sexual  types,  and  functions  are 
described  at  length.  All  the  functional  and  organic  disorders  peculiar  to 
women  are  discussed  in  an  exceptionally  rational  and  practical  manner. 
Throughout  the  pages  of  the  book  hygiene  and  prophylaxis  are  given  special 
attention.  The  book  is  altogether  valuable  and  desirable,  and  ought  to  be 
read  by  every  medical  student  and  practitioner,  particularly  the  latter." — 
Denver  Medical  Times. 


New  York  :  D.  APPLETON  &  CO.,  72  Fifth  Avenue. 


I 


tt  il 


/  ■••  * 


m 


A  New,  Thoroughly  Revised,  and  Enlarged  Edition  of 

QUAIN'S 
DICTIONARY  OF  MEDICINE. 

£y   VARIOUS   IVRITERS. 

Edited  by  Sir  RICHARD  Q.UAIN,  Bart.,  M.  D.,  LL  D.,  etc., 

Physician  Extraordinary  to  Her  Majesty  the  Queen ;  Consulting  Physician  to  the  Hospital 
for  Diseases  of  the  Chest,  Urompton,  etc. 

Assisted  by  FREDERICK   THOMAS   ROBERTS,  M.  D.,  B.  Sc, 

Fellow  of  the  Koyal  College  of  Physicians,  etc. ; 

And  J.   MITCHELL    BRUCE,  M.A.,  M.  D., 
Fellow  of  the  Royal  College  of  Physicians,  etc. 

V/ith  an  American  Appendix  by  SAMUEL  TREAT  ARMSTRONG,  Ph.  D.,  M.  D., 

Visiting  '       sician  to  the  Harlem,  Wilhird  Parker,  and  Riverside  Hospitals,  New  York. 


IN  TWO  VOLUMES. 


Sold  only  by  subscription. 


This  work  Is  primarily  a  Dictionary  of  Medicine,  in  which  the  several  diseases  are 
fully  discussed  in  alphabetical  order.  The  description  of  each  includes  an  account  of 
its  etiolo^'y  and  anatomical  characters;  its  symptoms,  course,  duration,  and  termi- 
nation ;  its  diagnosis,  pro;;nosis,  and,  lastly,  its  treatment.  General  Pathology  com- 
prehends articles  on  the  origin,  characters,  and  nature  of  disease. 

General  Therapeutics  includes  articles  on  the  several  classes  of  remedies,  their 
modes  of  action,  and  on  the  methods  of  their  use.  The  articles  devoted  to  the  subject 
of  Hygiene  treat  of  the  causes  and  prevention  of  disease,  of  the  agencies  and  laws 
affecting  public  health,  of  tha  means  of  preserving  ths  health  of  the  individual,  of  the 
construction  and  management  of  hospitals,  and  of  the  nursing  of  the  sick. 

Lastly,  the  diseases  peculiar  to  w  )men  and  children  are  discussed  under  their 
respective  headings,  both  in  aggregate  and  in  detail. 

The  American  Appendix  gives  more  definite  information  regarding  American 
Mineral  Springs,  and  adds  one  or  two  articles  on  particularly  American  topics,  be- 
sides introducing  some  recent  medical  ternii  and  a  few  cross-references. 

The  British  Medical  Journal  says  of  the  new  edition  : 

"The  original  purpose  which  actuated  the  preparation  of  the  original  edition 
was,  to  quote  the  words  of  the  preface  which  the  editor  has  written  for  the  new  edi- 
tion, '  a  desire  to  place  in  the  hands  of  the  practitioner,  the  teacher,  and  the  student  a 
means  of  ready  reference  to  the  accumulated  knowledge  which  we  possessed  of  scien- 
tific and  practical  medicine,  rapid  as  was  its  progress,  and  difficult  of  access  as  were 
its  scattered  records.'  The  scheme  of  the  work  was  so  comprehensive,  the  selection 
of  writers  so  judicious,  that  this  end  was  attained  more  completely  tlian  the  most 
sanguine  expectations  of  the  able  editor  and  his  assistants  could  have  anticipated. 
...  In  preparing  a  new  edition  the  fact  had  to  be  faced  that  never  in  the  history  of 
medicine  had  progress  been  so  rapid  as  in  the  last  twelve  years.  New  facts  have  been 
ascertained,  and  new  ways  of  looking  at  old  facts  have  come  to  be  recognized  as  true. 
.  .  .  The  revision  which  the  work  has  undergone  has  Ijeen  of  the  most  thorough 
and  judicnus  character.  .  .  .  The  list  of  new  writers  numbers  fifty,  and  among  them 
are  to  be  tound  the  names  of  those  who  are  leading  authorities  upon  the  subjects 
which  have  ceen  committed  to  their  care." 


New  York:    D.  APPLETON  &  CO.,  Publishers,  72  Fifth  Avenue. 


THE  SCIENCE  AND 
ART  OF  MIDWIFERY. 


BY 


WILLIAM  THOMPSON  LUSK,  M.A.,M.D., 

'Professor  of  Obstetrics  and  diseases  if  IV omen  and  Children  in  tht 

"Bellevue  Hospital  Medical  College  ;   Obstetric  Surgeon  to  tbt 

Maternitj/  and  Emergency  Hospitals ;  and  Gynaecologist 

to  the  Bellevue  Hospital. 


FOURTH  EDITION.    REVISED  AND  REWRITTEN. 

With  246  Illustrations. 

Svo.    Cloib,  S5  00;  sheep,  $6.00. 

"  It  was  the  pleasure  of  the  undersi^^ned  to  write  a  review  of  this  most  excellent 
and  masterly  work  on  obstetrics  when  it  appeared  in  its  first  edition.  The  present  is 
the  fourth,  an  edition  enlarged  and  revised.  It  is  a  model  of  recent  medical  literature 
in  obstetrics,  and  tan  not  but  give  gruat  credit  to  the  author  and  to  American  medi- 
cine. Modal  it  is  of  clear,  forcible,  and  beautiful  En;jlish,  of  pood  arrangement  of 
subject-matter,  and  of  thoroughness  of  modern  obstetric  exposition.  The  changes 
which  have  taken  place  in  the  theory  and  practice  of  obstetrics  since  the  issue  of  the 
last  edition  have  made  it  necessary  for  the  author  to  present  to  the  profession  what 
is  essentially  a  new  book.  Most  cheerfully  will  we  recommend  to  the  students  of  medi- 
cine a  study  of  Lusk.  It  ranks  well  with  Playfair,  and  is  second  to  no  book  in  our 
language."— Cil.\UNCEY  D.  Palmer,  in  the  Ohio  Medical  Journal. 

"  The  book  is  now  beyond  criticism,  for  it  has  been  accepted  by  the  unerring  judg- 
ment of  the  great  body  of  physicians.  We  congratulate  Dr.  Lusk  upon  this  reward 
for  the  immense  labor  he  has  bestowed  upon  it." — New  York  Medical  yournal. 

"  It  contains  one  of  the  b.st  expositions  of  the  obstetric  science  and  practice  of  the 
day  with  which  we  are  acquainted.  Throughout  the  work  the  authcr  shows  an  intimate 
acquaintance  with  the  literature  of  obstetrics,  and  gives  evidence  of  large  practical  ex- 
peri  nee,  great  discrimination,  and  sound  judgment.  We  heartily  recommend  the 
book  as  a  full  and  clear  exposition  of  obstetric  science,  and  safe  guide  to  student  and 
practitioner." — London  Lancet. 

"  It  is  but  a  short  time  since  we  had  occasion  to  review  this  work,  of  which  we 
•were  enabled  to  speak  in  the  highest  terms  of  praise.  The  rapid  advance  of  many 
departments  of  obstetrics  has  meantime  called  for  a  few  additions.  These  having 
been  made,  it  can  be  confidently  said  that  Lusk's  Midwifery  holds  a  high  place  among 
American  authors,  and  deserves  to  be  extensively  employed  for  reference,  and  recom- 
mended to  students  as  a  reliable  and  unusually  readable  text-book."— Cana</a  Medical 
and  Surgical  yournal. 

New  York :  D.  APPLETON  &  CO.,  72  Fifth  Avenue. 


t! 


|l 


u'> 


THE   PRINCIPLES  OF   SURGERY   AND 
SURGICAL   PATHOLOGY. 

General  Rules  governing  Operations  and  the  Application  of  Dressings. 

By    Dr.    HERMANN   TILLMANNS, 

Pro/i'ssor  at  the  Uiincnity  of  Lei(^{ig. 

Translated  from  the  third  German  edition  by  JOHN  ROGERS,  M.  D.,  New 
York,  and  BENJAMIN  TILTON,  M.  D.,  New  York. 

Edited  by  LEWIS  A.  STIMSON,  M.  D.,  Professor  of  Surgery  in  the  University 
of  the  City  of  New  York,  Medical  Department. 

8vo.     800  pages.     With  441  Illustrations. 

Cloth,  $5.00 ;  sheep,  $6.00. 

"  It  was  a  wise  combination  of  subjects  in  considerinp  the  principles  of  sur- 
gery and  its  pathology  in  the  same  treatise.  It  enables  the  surgeon  to  refer  to 
both  branches  of  the  subject  without  loss  of  time,  and  each  serves  to  accentuate 
the  importance  of  the  other.  Not  since  IJillroth's  classic  treatise  on  surgical 
pathology,  that  appeared  some  twenty-three  years  ago,  has  there  been  a  more 
satisfactory  exposition  of  surgical  pathology  than  here  given  by  Tillmanns.  It 
is  brought  down  to  the  immediate  present  uniler  the  light  afforded  by  the  most 
modern  researches  in  bacteriology.  A  student  should  be  taught  pathology 
before  he  is  instructed  in  surgical  diseases  and  injuries.  These  latter  he  will 
then  understand  with  a  clearness  that  coidd  not  be  possible  if  the  method  of 
teaching  were  reversed.  The  editor  and  the  translators  appreciating  this  fact 
have  duly  emphasized  it  in  bringing  out  and  making  available  as  a  text-book 
one  of  the  best  treatises  on  the  princii)Ies  of  surgery  and  surgical  pathology 
that  has  yet  been  written.  It  is  impossible  in  the  space  now  at  our  disposal  for 
us  to  do  more  than  express  our  opinion  of  this  excelbnt  work  and  to  commend 
it  to  student  and  practitioner  as  a  safe  and  scientific  guide,  which  we  do  here 
and  now." — Buffalo  Medical  and  Surgical  Journal. 

"It  is  strange  that  this  excellent  work  has  been  allowed  to  pass  to  a  third 
edition  in  German  without  a  translation  in  English  until  this  time.  The  ar- 
r.mgement  of  the  book  is  different  from  that  of  the  average  text-book  on  the 
subject.  It  is  divided  into  three  sections  :  First,  General  I'rinciples  governing 
Surgical  Operations  ;  second,  Methods  of  ajijjlying  Surgical  Dressings  ;  and 
third.  Surgical  Pathology  and  Thcrajiy.  The  work  of  translators  and  editor 
has  been  excellently  done.  The  book  is  printed  and  bound  in  the  correct  and 
elegant  style  for  which  the  publishers  are  noted.  T  he  work  is  strictly  modern, 
and  none  of  the  recent  advances  in  surgical  pathology  have  been  left  uncon- 
sidered."— Chicago  Medical  Kecorder. 

"  It  is  just  the  book  for  surgeons  who  entered  practice  before  surgical  bac- 
teriology had  been  developed  so  as  to  afford,  as  il  now  does,  a  firm  founda- 
tion for  the  best  clinical  work.  By  its  aid  one's  knowledge  of  the  results  of 
most  recent  investigations  can  be,  so  to  speak,  brought  up  to  date.  No  sur- 
geon, however  experienced,  can  read  it  without  having  his  tec/mique  con- 
sciously or  unconsciously  improved,  and  his  grasp  upon  the  fixed  facts  of  surgical 
science  made  more  secure.  In  illustrations,  type,  paper,  and  binding,  Till- 
manns's  '  Surgical  Pathology'  is  up  to  the  Appleton  standard,  and  that  stand- 
ard, as  we  all  know,  is  unsurpassed." — Canada  Lancet. 


New  York :  D.  APPLETON  &  CO.,  72  Fifth  Avenue. 


THE 

New  York  Medical  Journal 

A  WEEKLY  REVIEW  OF  MEDICINE. 

EDITED   BY 

FRANK  P.   FOSTER,  M.  D. 


i 


THE  PHYSICIAN  who  would  keep  abreast  with  the  advances  in 
medical  science  must  read  a  live  weekly  medical  journal,  in  which 
scientific  facts  are  presented  in  a  clear  manner ;  one  for  which  the 
articles  are  written  by  men  of  learninj;,  and  by  those  who  are  good 
and  accurate  observers;  a  journal  that  is  stripped  of  every  feature 
irrelevant  to  medical  science,  and  gives  evidence  of  being  carefully  and 
conscientiously  edited ;  one  that  bears  upon  every  page  the  st?.mp  of 
desire  to  elevate  the  standard  of  the  profession  of  medicine.  Such  a 
journal  fulfills  its  mission — that  of  educator— to  ihe  highest  degree, 
for  not  only  does  it  inform  its  readers  of  all  that  is  new  in  theory 
and  practice,  but,  by  means  of  its  correct  editing,  instructs  them  in 
the  very  important  yet  much-neglected  art  of  expressing  thoir  thoughts 
and  ideas  in  a  clear  and  correct  manner.  Too  much  stress  tan  not  be 
laid  upon  this  feature,  so  utterly  ignored  by  the  "average"  medical 
periodical. 

Without  making  invidious  comparisons,  it  can  be  truthfully  stated 
that  no  iiiedical  journal  in  this  country  occupies  the  place,  in  these 
particulars,  that  is  held  by  The  New  York  Medical  Journal.  No 
other  journal  is  edited  with  the  care  that  is  bestowed  on  this ;  none 
contains  articles  of  such  high  scientific  value,  coming  as  they  do  from 
the  pens  of  the  brightest  and  most  learned  medical  men  of  America. 
A  glance  at  the  list  of  contributors  to  any  volume,  or  an  examination 
of  any  issue  of  the  Journal,  will  attest  the  truth  of  these  statements. 
It  is  a  journal  for  the  masses  of  the  profession,  for  the  country  as  well 
as  for  the  city  practitioner  ;  it  covers  the  entire  range  of  medicine  and 
surgery.  A  very  important  feature  of  the  Journal  is  the  number 
and  character  of  its  illustrations,  which  are  unequaled  by  those  of  any 
other  journal  in  the  world.  They  appear  in  frequent  issues,  whenever 
called  for  by  the  article  which  they  accompany,  and  no  expense  is 
spared  to  make  them  of  superior  excellence. 


Subscription  price,  ^^.oo  per  annum.     Volumes  begin  in 
January  and  July. 

PUBLISHED  BY 

D.  APPLETON  &  CO.,  7a  Fifth  Avenue,  New  York. 


DISEASES  OF  THE  EAR. 


is 


Ik 


A  TEXT-BOOK  FOR  PRACTITIONERS 
AND  STUDENTS  OF  MEDICINE. 

By  Edward  Bradford  Dench,  Ph.  B.,  M.  D., 

Professor  of  Otology  in  the  Bellevue  Hospital  ^Tc(!^cal  College  ;  Aural  Surgeon  to  the  New  York 

Eye  and  liar  Infirmary,  etc. 

8vo,  645  pages. 

With  8  Colored   Plates  and  132  Illustrations  in  the  Text. 

Clof/t,  $^.00;   sheep,  $6.00. 

"An  pxamination  of  the  contents  will  prove  that  this  volume  carries  its  raison 
cTelre.  It  embodies  in  a  most  satisfactory  manner  the  known  facts  o'  otolojjy,  hav- 
ing; incor|)orated  must  successfully,  and  witli  little  bias,  the  reci^nt  advancements  that 
have  been  made  in  this  branch.  KecoKnizing  the  aiil  which  comes  from  a  faithful 
reproduction  of  the  anatomical  structures  concerned,  an*^'  f.om  showing  the  site  of 
operative  pmcetlures,  the  plates  have  been  prepar»".!  .vith  all  the  care  and  precision  of 
nKxlern  ennravinj;  art  from  the  specimens  thenifL-lves.  '1  he  hijjh  c!:is.s  of  illustrations 
in  the  work  is  worthy  of  special  praise.  The  text  maintains  a  character  that  will  rank 
the  author  as  one  of  our  best  otolo^jical  writers.  He  I'as  paid  marked  attention  to  the 
physioUjtjical  basis  of  aural  studies  and  to  the  functional  examination  in  cases  of  ear 
disease.  In  mentionin}^  tnatment  he  has  t;one  into  manipulative  details  that  olhtc 
writers  have  omitted,  and  yet  which  are  very  necessary  to  the  student  and  practitioner 
who  may  have  never  had  a  chance  to  study  and  observe  these  matters  in  s])ecial  aural 
clinics.  The  author  is  perhaps  more  fond  of  oi)erative  procedures  in  middle-car  dis- 
ease than  some  of  his  colleagues,  but  he  has  jjiven  us  what  we  have  desired  a  j^ood 
modern  resume  on  the  benefits  to  be  derived  Ircni  such  operations."— C't>/ttw^//.f  Med- 
ical yourita!. 

"  One  ha«  only  to  read  this  volume  in  order  to  see  its  worth.  Whether  there  was 
need  at  present  for  a  new  text-book  on  olnluf^y  must  l:e  seen  from  the  success  wnich 
will  be  met  with  by  this  work  f)f  Dr  Dench.  However,  we  have  no  hesitancy  in  say- 
ing; that  it  is  the  best  work  of  its  kind  by  an  Amerir.in  author.  l)r  Dench  is  j;erhaps 
one  of  the  leadin;,'  exponents  of  intra-tympanic  surgery,  and  while  his  views  upon  this 
si'.bject  are  perhaps  more  radical  tiian  the  majority  of  aural  surgeons,  yet  they  must 
be  thoutjhtfully  considered,  coming  as  they  do  from  one  who  is  so  well  and  favorably 
known.  It  is  almost  imiiossible  to  display  any  originality  in  writing  a  work  upon  the 
ear,  yet  in  this  texi-biok  the  autlior  has  dealt  in  no  superficial  va(;aries,  but  he  speaks 
as  one  with  a  !ar„'e  amount  of  clinical  experience,  and  thus  pives  to  the  reader  those 
points  wliicli  are  of  practical  importance." — Atlanta  Medical  aHu  i>ingtcal  Journal. 

"  In  this  valuable  work  minute  patholojjy  has  not  been  considered  extensively,  be- 
cause it  has  been  the  aim  of  the  author  to  adapt  it  to  the  needs  of  the  (general  prac- 
titi'inerand  special  sur^;eon.  Dr.  Dench  h.as  written  at  len;jth  U|)on  the  importance 
of  a  thorou};h  functional  examination,  which  many  W(  rks  upon  otoloj.;y  have  failed  to 
eriphasize.  He  has  placed  the  results  of  recent  investijjations  at  the  disposal  of  the 
re.'.der  in  such  a  manner  as  to  enable  him  to  use  them  in  diap;nosis.  The  author  has 
w -itten  from  his  extensive  personal  experiL'nce  in  tdvocatinjj  operative  pi,/>.Jures 
upon  the  middle  ear.  On  the  whole,  the  work  is  an  exceedinj^ly  j;o<)d  one,  and  admi- 
rably adapted,  as  was  the  author's  aim,  to  the  tjcneral  practitioner  and  the  special 
surgeon."  —A'd«,fjj  City  Medical  Record. 


New  York:  D.  APPLETON  &  CO.,  72  Fifth  Avenue. 


Appletons 
lopular  Science  Alonthly. 

Edited  by   WILLIAM  JAY  YOU  MANS. 

The  Popular  Science  Mo  ithly  is  without  a 
competitor. 

It  is  not  a  technical  magazine. 

It  stands  alone  as  an  educator,  and  is  the 
best  periodical  for  people  ivho  think. 

ylll  its  articles  are  by  ivr iters  of  long  prac- 
tical acquaintance  with  their  subjects,  and  are 
written  in  such  a  manner  as  to  be  readily  2tn- 
derstood. 

It  deals  particularly  with  those  general 
and  practical  subjects  which  are  of  the  greatest 
interest  and  importance  to  the  people  at  large. 

It  keeps  its  readers  fully  informed  of  all 
that  is  being  done  in  the  b'^oad  field  of  science. 

Illif^trations,  from  dra^vings  or  photo- 
graphs, are  freely  used  in  all  cases  in  which 
the  text  may  be  thereby  elucidated. 

Examination  of  any  recent  number  will 
more  than  confirm  the  foregoing. 


$S.oo  per  annum  ;  single  copy,  ^o  cents. 
Ne,w  York:  D.  APPLETON  ir  CO..  72  Fifth  Avenue. 


THE  RULES  OF 

ASEPTIC  AND  ANTISEPTIC 

SURGERY. 

A  PRACTICAL  TREATISE  FOR  THE  USE  OF  STUDENTS 
AND  THE  GENERAL  PRACTITIONER. 

By  ARPAD  Q.  GERSTER,  M.  D., 

Professor  of  Siiigeiy  at  the  New  Yoik  I'olyclinic  ;  Visiting  Surgeon  to  the 
German  Hospital  and  to  Mount  Sinai  Hospital,  New  York. 

THIRD  EDITION,    REVISED. 

8vo.    Illustrated  with  Two  Hundicd  and  Forty-eight  Fine  Enerravings. 

Cloth,  $5.00;  sheep,  $6.00. 


Tlic  attention  of  the  Medical  Profession  is  invited  to  the  following  points  of  ex- 
cellence in  this  work : 

It  deals  only  with  matters  of  practical  interest  to,  and  (juestions  that  arc  likely  to 
arise  daily  in  the  work  ot"  the  jiraetieini;  [ihvrsician.  Its  scope  is  a  terse  yut  okar  ex- 
position of  the  priiii'iples  f^oviTninff  modern  operative  surgery.  It  enters  into  the 
practical  details  of  all  the  varyiiif,'  eoiulitioiis  of  the  apiilii'Mtion  of  the  antiseptic 
method  as  hrought  about  by  emergencies.  Every  important  principle  is  clearly 
il!u>tr.ited  by  eitations  from  actual  cases  occurrinj,'  in  tliu  author's  practice. 

It  is  not  intended  to  take  the  place  of  any  text-booU  on  .-urL'i  ry,  but  rather  to 
sujiply  a  need  which  exists  in  every  work  on  the  Kul)ject  in  the  Kufrlish  huitrua;,'e,  by 
furnishin^'  information  on  the  subjei't  of  Asci>>is  and  Anti>epsis,  with  which  no 
hook  on  Hiir^^cry  deals  to  an  extent  demanded  by  modern  inethiHls.  It  is,  in  sliort, 
a  su]>plement  to  all  suri,'ieal  text-books. 

The  illustrations  are  typn-irravures,  made  from  plioto;.'ra])hic  negatives  taken 
from  life,  and  ..re  inarvuls  of  ln'auty,  artistic  elcjrance,  and  fidelity  ;  each  illustnition 
boiiijif  a  .•'aithful  representation,  by  the  camera,  of  the  details  of  the  applici-tion  of  all 
important  antiseptic  dressin^rs  and  apparatus,  apiiniachinir  nearer  to  an  actual 
demonstration  than  has  ever  before  been  attempted  to  be  dune  in  any  medical  work. 
With  the  execution  of  a  few  baeterii'lnirioal  ilbistratinns  taki'ii  from  Koch,  liosen- 
bach,  and  Bumtn,  the  ilbi-trationa  are  from  nepitives  made  ('//  ffie  operating-room, 
and  are  (jf  a  eharueter  now  for  the  first  time  employed  in  a  medical  work. 

The  work  hab  boea  adopted  by  the  Medical  Department  of  the  United  States  Army, 


New  York:  D.  APPLETON  Si  CO.,  72  Fifth  Avenue. 


